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MIDTERM REVIEW
MEDICAL INSURANCE
| Term | Definition |
|---|---|
| BENEFICIARY | -the person receiving the benefits of an insurance company to pay benefits directly to the physician. |
| ASSIGNMENT OF INSURANCE BENEFITS | -statement authorizing the insurance company to pay benefits directly |
| BIRTHDAY RULE | -the rule governing the hierarchy of co-ordination of benefits |
| CAPITATION | -a method of payment for health services in which an individual or institutional provider is paid a fixed, per capita amount for each person served without regard to the actual number of nature of services provided to each person |
| CLAIM | -a demand to the insurer by the insured person for the payment of benefits under a policy |
| CPT-4 | -a list of descriptive terms and identifying codes that are used for reporting medical services and procedures performed by physicians. Its purpose is to provide a uniform language that accurately identified medical, surgical, and diagnostic service |
| DEDUCTIBLE | -a statement in an insurance policy that the insuring company will pay the expenses incurred after the insured person has paid a specified amount. |
| COORDINATION OF BENEFITS (COB) | -The provision in an insurance contract that limits benefits to 100% of the cost. |
| CROSSOVER CLAIM | -A claim for benefits under both Medicare and Medicaid. |
| DISABILITY | -the condition resulting from illness or injury that makes an individual unable to be employed. |
| ESTABLISHED PATIENT | -a patient who has received care from the physician within the last 3 years. |
| FEE SCHEDULE | -a list of services or procedures indemnified by the insurance company and of the specific dollar amounts that will be paid for each service. |
| FRINGE BENEFIT | -a Benefit granted by an employer that involves a money cost but Does not affect the basic wages rates of employees. |
| GROUP POLICY | -a policy that covers a group, for example, all employees of one company - under a master contract. |
| ICD-9-CM | -INTERNATIONAL CLASSIFICATION OF DISEASES, 9TH REVISION, CLINICAL MODIFICATION) a system for classifying diseases and operations to facilitate collection of uniform and comparable health. |
| INDEMNITY | -a benefit paid by an insurer for a loss insured under a policy |
| INDIVIDUAL POLICY | -a policy usually held by a person who does not qualify for a group policy. |
| MEDICARE | -under Social Security for the patient >65 and disabled persons receiving social Security or railroad retirement checks, >2, includes disabled workers,persons who became incapacitated <22,disabled widows/dependent widowers. *many also file secondary ins. |
| MEDICARE PART A | -HOSPITAL INSURANCE. (HIGH DEDUCTIBLE) |
| MEDICARE PART B | -MEDICAL INSURANCE. CERTAIN DISABLED PERSONS UNDER THE AGE OF 65 YEARS ARE ALSO ELIGIBLE FOR MEDICARE. PATIENT TO MEDI-PART B 20%/80% DEDUCTIBLE. plus pt. pays whatever is not cover under the policy |
| TRICARE AKA CHAMPUS | -dependent of military personnel receive in-hospital treatment by civilian physicians at the expense of the government. Deductible or families of active duty members pay @ $25 or sm. for hospital. pay |
| CHAMPVA | -established for the spouses and dependent of veterans suffering total, permanent as well, service-connected and for the surviving spouses and dependent children of veterans who have died as a result of service-connected |
| HEALTH MAINTENANCE ORGANIZATION (HMO) | -pt. is charged a pre-determined: Employer are required to offer federally qualified HMO as an option |
| EMBLEM, HIP, UNITIED HEALTH CARE, METROPLUS, BLUE CROSS/BLUE SHIELD. | -examples of HMO'S |
| S.O.F. | -signature on file. |
| GP | -General Practitioner |
| Path | -pathology |
| CVA | -Cerebral Vascular Accident |
| SH | -social history |
| PX | -physical exam |
| DR | -delivery room |
| PFT | -Pulmonary Function Test |
| WDWN | -Well Developed and Well Nourishment |
| FUO | -Fever Of Unknown Origin |
| SUPERBILL | -employer may send its own claim for to pt. who will attach to insurance form |
| FIVE REASONS FOR REJECTED CLAIM | -Dx missed or incomplete -Dx is not coded accurately -Dx does not correspond with treatment (unless otherwise explained) -Charges are not itemized -pt's group, member, or policy# is missing or incorrect -pt's info sect. incomplete or signature is mis |
| CMS - Centers for Medicare and Medicaid Services: | -degree of effort invested by physician in a particular service or procedure and amt of time. Designed to provide national uniform payments after being adjusted to reflect the differences in practice costs across geographic areas. |
| 1. DIAGNOSTIC CODING - ICD-9-CM | 3 Volumes V1 - DISEASES: # INDEX V2 - DISEASES: A-Z LIST V3 - TAB. LIST AND ALPHA INDEX OF PROCEDURES ( E and V codes) |
| 2. CURRENT PROCEDURAL TERMINOLOGY (CPT-4). | 6 sections -Evaluation and Management (EM) -Anesthesiology -Surgery -Radiology -Pathology and Laboratory -Medicine |
| TWO (2) COMMON TYPES OF MEDICAL CODING | ICD - 9th CM International Classification of Diseases, 9th Revision,(Clinical Modification. CPT-4th : (Physician's Current Procedural Terminology) |
| CODING | -converting verbal descriptions of diseases, injuries, and procedures into numerical and alphanumerical designations. |
| (PRSO) PROFESSIONAL STANDARDS REVIEW ORGANIZATION | -a group of physicians working with the government to review cases from hospital admission and discharge under government guidelines sometimes referred to as PEER REVIEW. |
| RIDER | -a legal document that modifies the protection of a policy. |
| PREPAID PLAN | -a plan that provides all covered services to a policyholder for payment of a monthly fee. |
| SERVICE BENEFIT PLAN | -a plan that agrees to pay for certain surgical and medical services and that is a monthly fee. |
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