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Intro Health Ins_1

Vocabulary Part 1

TermDefinition
health insurance contract that provides money to cover all or a portion of the cost of medically necessary care
health maintenance organization managed care organization that provides low cost health care for its members in exchange for stringent guidelines and a limited choice of providers
deductible patient's annual financial responsibility that must be met before the health care plan begins paying for health care costs
in-network provider a health care professional who provides services to individuals covered by a particular health insurance policy and who accepts the insurance company's approved fee for each service
out-of network A health care professional who does not contract with insurance companies and does not accept an insurance company's approved fee for services
independent practice association one of the 4 models of an HMO. This model contracts directly with physicians who practice in their private offices. Physicians may be compensated by the insurance carrier by capitation, fee for service, or discounted fee for service
managed care organization any method of organizing health care providers that provides access to high-quality, low cost care
maximum allowable fee dollar amount typically considered payment-in-full by an insurance company and an associated network of healthcare providers. The Allowable Charge is typically a discounted rate rather than the actual charge.
policyholder owner/ purchaser of the health insurance policy
preferred provider organization (PPO) Health care providers, including physicians, hospitals, clinics, and pharmacies, which contract with private payers to provide care to the plan's members
accept assignment physicians and providers who accept the benefit paid by the insurance company for a specific service as payment in full for that service; the patient does not have to pay any difference
assignment of benefits authorization given by the patient that identifies who actually receives the insurance payment
Fee for Service AKA: Indemnity or Traditional plans; health insurance plans that allow members to choose their health care providers; members share in the cost of their health care with deductible and coinsurance payments
capitation reimbursement method that depends on the number of individuals covered by the health insurance contract; used to pay primary care physicians
preauthorization determines medical necessity of the treatment
precertification determines if treatment is covered by the insurance company
referral pre-approval or health care for an HMO member by a primary care provider
premium payment made by a member or subscriber for coverage under a policy; usually on a monthly or yearly basis
pre-existing condition health problem that exists before enrolling in or becoming eligible for a health plan
Created by: tina.reynolds