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Ins_2

Insurance Principles

TermDefinition
Employee Retirement Income Security Act (ERISA) A federal law that sets minimum standards for self-insured health plans to provide protection for individuals who participate in these plans.
Exception Provision of a policy that eliminates coverage
Exclusion Provision in a policy that denies coverage
Explanation of Benefits (EOB) Itemized statement provided to members after a claim has been processed
Express contract A verbal or written contract in which a patient and a provider agree on certain terms or conditions before the care takes place
Fee schedule List of maximum dollar allowances that apply under a specified contract
Group policy Health insurance plan purchased by an employer or organization and offered to the employees or members
Health insurance claim number (HICN) Numbers assigned to Medicare beneficiaries by the Social Security administration; consists of nine digits and a numeric or alphanumeric prefix or suffix
Health maintenance organization (HMO) A managed care organization that provides low cost health care for its members in exchange for stringent guidelines and a limited choice of providers
Implied contract A contract between a patient and a provider in which no formal exchange takes place between the provider and the patient, either verbally or in writing
Indemnity plans Plans that allow members to choose their health care providers; members share in the cost of their health care with deductibles and coinsurance payments; also called a traditional health plan
Insurance adjustments Any remaining portion once an insurance carrier meets its financial responsibility and the patient responsibility is determined; portion must be written off of the account according to the providers contract
Legend Provides the meaning of symbols. abbreviations, and term used in explanations; also called a key
Explanation of Payment (EOP) Itemized statement provided to providers after a claim has been processed
Created by: tina.reynolds