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Intro Health Ins_2
Vocabulary Part 2
| Term | Definition |
|---|---|
| co-insurance | patient's financial responsibility once all covered expenses have been reimbursed by the health care plan |
| co-pay | specific dollar amount the patient must pay the provider for each encounter; also called co-payment |
| EPO (Exclusive Provider Network) | managed care organization that contracts with health care providers to obtain services for members; members are restricted to using participating providers |
| Coordination of Benefits | statement of how benefits are paid when the patient is covered by more than one insurance policy so the total amount of the bill is not exceeded |
| dependent | individual who is covered by the insured's health insurance policy |
| benefits | health insurance coverage a member receives and the specific conditions under which the coverage is provided |
| eligibility | conditions members must meet to be eligible for coverage under a policy |
| (COBRA) Consolidated Omnibus Budget Reconciliation Act | Federal act that gives former employees the right to continue their existing health care coverage under their employer's plan for a limited time at the former employee's expense |
| medical necessity | determination by an insurance payer using evidence-based clinical standards that a procedure or service is medically necessary |
| fee schedule | list of maximum dollars allowed for each procedure/service under a a specified contract |
| primary care physician | physician responsible for providing all routine health care and determining the need for referrals to physician specialists; usually includes family practice, internal medicine, and pediatric physicians |
| referring physician | physician who arranges for the patient to see another physician or health care provider |
| preexisting condition | health conditions that were treated or existed before the individual was covered by the health insurance policy; expenses arising from pre-existing conditions are not usually paid by the insurance company |
| exclusions | situations that are not covered by a health insurance policy; examples may include self-inflicted injury, work-related injury, and injuries suffered during military service; expenses arising from exclusions are not paid by the insurance company |
| timely filing | (AKA; claims time limit) number of days allowed to submit a claim |
| primary payer | term use to describe which health insurance policy will pay first when an individual is covered by more than one health insurance policy |
| secondary payer | term used to describe which health insurance policy will pay second when an individual is covered by more than one health insurance policy |
| reimbursement | amount paid by insurance carrier |
| birthday rule | determines the primary payer when the patient is a child living with both parents and each parent carries health insurance |
Created by:
tina.reynolds
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