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insurance principals
| Term | Definition |
|---|---|
| Medicaid | Health insurance program in which the federal government makes payments to states under the Federal Medicaid Assistance Percentage (FMAP); individuals who qualify for Medicaid meet federal and state set income requirements |
| Medical necessity | The determination by an insurance payer using evidence-based clinical standards that a procedure or service is medically necessary |
| Medical policy | Medical guidelines utilized by insurance carriers to determine coverage decisions |
| Medicare Administrative Contractors (MAC) | One of the 15 contractors responsible for process and payment of Medicare Part A and Part B claims |
| Medicare Part A | Medicare benefits that pay for portions of inpatient hospital care, skilled nursing care, home health care, and hospice care; also called Hospital Insurance Benefits |
| Medicare Part B | Medicare benefits that help pay for provider services, outpatient hospital services, medical equipment, and other supplies and services; also called Supplemental Medical Insurance |
| Medicare Part C | CMS contracts with private health insurance companies to offer Medicare beneficiaries Medicare Advantage plans with comparable benefits to the original Medicare plans |
| Medicare Part D | Private prescriptions plans that help with the cost of prescription medication for Medicare beneficiaries |
| Open enrollment | A period of time each year when enrollment is open to members and providers for Medicare |
| Open-panel HMO | Allows providers who meet their standards to join the HMO and see patients who are HMO members |
| Point of service (POS) plan | Hybrid of the PPO and HMP plans; member can choose from a primary or secondary network |
| Policyholders | Owners of a health insurance policy |
| Integrity | Adherence to moral and ethical principles |
| Latex sensitivity | Occurs when someone is allergic to latex, a component of commonly used medical equipment, such as disposable rubber gloves; can cause serious harm |
| Malpractice | The professional liability of providers involved in the delivery of health care |
| Medicolegal | Legal aspects of the practice of medicine |
| Morals | The difference between right and wrong or how a person perceives he/she should behave in a given situation |
| Negligence | Failure to do what a prudent person would normally expect a provider to do in a similar circumstance |
| Nonverbal communication | Written forms of communication, facial expressions, physical gestures, and body positions and movements |
| Patients Bill of Rights | A list developed by the American Hospital Association (AHA) that delineates patients rights; also outlined in the Affordable Care Act |
| Phlebitis | Inflammation of blood vessel; can be caused by a disease or a complication of medical procedures |
| Privacy | A patients right to keep his/her information from being disclosed |
| Privileged communication | Any communication involving patient care that takes place between a provider and a patient |
| Scope of duty | A legal term that refers to the understanding that the provider has a duty to diagnose and treat a patient in accordance with the standards of acceptable medical practice and to continue to do so until the termination of the relationship |
| Social media | Media specifically designed for social interaction, includes online technology tools that enable persons to communicate and share resources and information |
| Stressors | Any agents or conditions that cause stress |
Created by:
tina.reynolds
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