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Health Insurance Terminology Commercial

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