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Insurance
Health Insurance Terminology Commercial
| Question | Answer |
|---|---|
| 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 deductible, 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 process 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:
wenchie040
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