patient's financial responsibility once all covered expenses have been reimbursed by the health care plan

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

individual who is covered by the insured's health insurance policy

health insurance coverage a member receives and the specific conditions under which the coverage is provided

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

determination by an insurance payer using evidence-based clinical standards that a procedure or service is medically necessary

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

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

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

(AKA; claims time limit) number of days allowed to submit a claim

term use to describe which health insurance policy will pay first when an individual is covered by more than one health insurance policy

term used to describe which health insurance policy will pay second when an individual is covered by more than one health insurance policy

amount paid by insurance carrier

determines the primary payer when the patient is a child living with both parents and each parent carries health insurance

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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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