Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Carnegie Insurance &
Health Insurance Terminology Commercial (MA Fall 2014)
| Term | Definition |
|---|---|
| Allowable | Maximum amount of money that many third-party payers allow for a specific procedure/service |
| Actual charge | Charge the physician submits for his services to the insurance carrier |
| Authorization | Number given by the insurance company authorizing approval of a procedure/service. Does not guarantee payment |
| Beneficiary | Person entitled to receive benefits from an insurance policy |
| Birthday Rule | Insurance rule-when an individual is covered under two insurance policies, the policy holder whose birthday comes first in the calendar year, month and day- not year- is primary/first payer |
| Capitation | Payment used by managed care plans; fixed payment is reimbursed to the provider for patients enrolled under his/her name |
| Carrier | Insurance companies that provide the policy and benefits |
| CHAMPVA | Benefit program for the spouse and dependent children of veterans with service connected disabilities or of veterans who died as a result of service connected disabilities |
| Co-insurance | Policy holder and insurance company share the cost of covered benefits (e.g. 80/20) |
| Commercial insurance plans | Also called Private Insurance- reimbursement is based on the policy |
| Co-payment | Sum of money paid at the time of medical service |
| Deductible | Fixed dollar amount that must be paid, "met" once a benefit year, before the insurance company begins to cover medical expenses |
| Dependent | A person covered under the primary insured's policy |
| Effective date | Date on which an insurance policy takes effect |
| Exclusions | Limitations on an insurance contract for which benefits are not payable |
| Explanation of Benefits | A claim summary indicating what services were covered, not covered and why, contains information on deductibles, co pays and allowed amounts |
| Guarantor | Person responsible for paying a medical bill |
| Participating provider | Physician who entered into a written contract with a specific insurance carrier and accepts their payment as payment in full and abides by their rules |
| Referral | Authorization for an HMO patient to be seen by a physician other than their PCP |
| TPA- Third Party Administrator | Organization that processes health claims for a health plan |
| TRICARE | Government sponsored program under which dependents of active duty military personnel, retirees, and family members receive medical care |
| Workers Compensation | Medical and disability insurance to cover employees in the event of a work related injury |
Created by:
ma2b
Popular Medical sets