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Intro Health Ins_2

Vocabulary Part 2

TermDefinition
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