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Reimbursement means to be repaid.
Capitation involves the payment to a health care provider regardless of whether the patient comes into the facility for a visit or how frequently the patient visits the provider.
Insurance purchased contract (policy) in which the purchaser (insured) is protected from loss by the insurer’s (the company) agreeing to reimburse for such loss.
Beneficiary One who is eligible to receive or is receiving benefits from an insurance policy or a managed care program.
Claim Request for payment by the insured or the provider for services covered.
Coverage Types of diseases, conditions, and diagnostic and therapeutic procedures for which the insurance policy will pay.
Payer Party who is financially responsible for reimbursement of health care costs.
Premium Payment required to maintain policy coverage.
Rider Policy amendment that either increases or decreases benefits.
Policy Written contract between insurance company and subscriber (insured) that specifies the coverage, benefits, exclusions, co-pays, deductibles, benefit period, and so on.
Subscriber Person who elects to enroll or participate in managed care or purchase of health care insurance.
Fiscal Intermediary Contractor that manages the health care claims.
Exclusion Specific conditions or hazards for which a health care policy will not grant benefit payments.
Deductible Amount of cost that the beneficiary must incur before the insurance will assume liability (their part) for the remaining cost.
Co-Payment Type of cost-sharing in which the insured(subscriber) pays out-of-pocket a fixed amount for health care service.
Benefit Period Time frame in which the insurance benefits are covered; varies from insurance policy to policy.
Benefit Amount of money paid for specific health care services or in managed care, the health care services that will be provided or for which will be paid.
Prospective Payment Method of determining the reimbursement to a health care provider based on predetermined factors, not on individual services.
Discounted Fee For Service • When a physician or other health care provider offers services at a discounted rate, that is the fee is lower what they would ordinarily charge to person walking in off the street.
Fee-for-Service This term is assigned to the payment for services rendered by the health care provider, whether it is a physician, facility, or another clinician.
Encounter Form A data collection device that facilitates the accurate capture of ambulatory care diagnoses and services.
Charges Fees or costs are also called charges.
When the ICD-9-CM diagnosis and procedures codes are used to derive the DRG by the flowchart, this is known as: Grouper
What is the HCFAs prospective payment system for hospital-based ambulatory care based? Ambulatory Patient Classifications
What is the prospective payment for acute care is based? Diagnosis Related Groups
What is the process of submitting claims or rendering invoices? Billing
The process of determining the most accurate DRG payment is known as: Optimization
Created by: Mackey1