Electronic Data Interchange Involving the computerized transfer of health care information between 2 parties for specific purposes.

National Provider Number # assigned to Providers by CMS for submitting insurance claims.

Supporting Claim Documentation

Documentation such as charts notes, labs, etc., required by many insurance companies when filing a claim.

Most carriers allow claims to be filed up to 1 year after the service has been provided, but for some it's 90 days. PFL claims will be rejected.

Federal Health Insurance program for people over age 65.

Hospital Insurance that is automatic if you receive Soc Sec benefits.

Fee-for-service, optional program that requires insured to pay income-based premiums.

Medicare Advantage Managed Care

Prescription Drug Coverage (limited)

Worker's Compensation insurance covers employees injured in the workplace or suffering from a workplace-related illness.

(formerly CHAMPUS) Government insurance program for active duty and retired military personnel.

Centers for Medicare and Medicaid Services

Advanced Beneficiary Notice (or waiver) that must be signed by Medicare patients. Patients agree to pay for specified procedure that might not be covered by Medicare.

Out-of-Pocket Expenses

Patient's responsibility including deductibles and co-pays and amount that is left after insurance covers.

1st payer, usually responsible for more money or higher charge

MSP rules (Medicare Secondary Payer) - where the Primary Insurance is Primary and Medicare is secondary (patient cannot choose).

Physician Fee Schedule

The amount the Provider charges for each procedure performed. Cannot charge more or less based on the insurance or patient.

Verification of (Insurance) Benefits Verifying insurance coverage either by calling (in-person) of by computer program. Usually is completed before the appt.

Contacting the insurance company to obtain permission for a procedure.

Coordination of Benefits Determining the Primary / Secondary insurances

Fixed $ amount that the patient pays

Monetary amount patient must pay before insurance kicks in.

Uniform billing format used for medical claims.

MCD - Health benefit program for low-income patients. ALWAYS billed 2nd.

Primary Care Provider / Gatekeeper who arranges for care / specialists / hospitalizations.

Insurance through government for disabled veterans.

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Mod 5 Ch 15

Ch 15 Medical Insurance

Term	Definition
EDI	Electronic Data Interchange Involving the computerized transfer of health care information between 2 parties for specific purposes.
NPI	National Provider Number # assigned to Providers by CMS for submitting insurance claims.
Supporting Claim Documentation	Documentation such as charts notes, labs, etc., required by many insurance companies when filing a claim.
Past Filing Limits	Most carriers allow claims to be filed up to 1 year after the service has been provided, but for some it's 90 days. PFL claims will be rejected.
Medicare	Federal Health Insurance program for people over age 65.
Medicare Part A	Hospital Insurance that is automatic if you receive Soc Sec benefits.
Medicare Part B	Fee-for-service, optional program that requires insured to pay income-based premiums.
Medicare Part C	Medicare Advantage Managed Care
Medicare Part D	Prescription Drug Coverage (limited)
WC	Worker's Compensation insurance covers employees injured in the workplace or suffering from a workplace-related illness.
Tri-Care	(formerly CHAMPUS) Government insurance program for active duty and retired military personnel.
CMS	Centers for Medicare and Medicaid Services
ABN	Advanced Beneficiary Notice (or waiver) that must be signed by Medicare patients. Patients agree to pay for specified procedure that might not be covered by Medicare.
Out-of-Pocket Expenses	Patient's responsibility including deductibles and co-pays and amount that is left after insurance covers.
Primary Payer	1st payer, usually responsible for more money or higher charge
Secondary Payer	MSP rules (Medicare Secondary Payer) - where the Primary Insurance is Primary and Medicare is secondary (patient cannot choose).
Physician Fee Schedule	The amount the Provider charges for each procedure performed. Cannot charge more or less based on the insurance or patient.
VOB	Verification of (Insurance) Benefits Verifying insurance coverage either by calling (in-person) of by computer program. Usually is completed before the appt.
Pre-Authorization	Contacting the insurance company to obtain permission for a procedure.
COB	Coordination of Benefits Determining the Primary / Secondary insurances
Co-Pay	Fixed $ amount that the patient pays
Co-Insurance	Fixed % that the patient pays
Deductible	Monetary amount patient must pay before insurance kicks in.
CMS-1500	Uniform billing format used for medical claims.
Medicaid	MCD - Health benefit program for low-income patients. ALWAYS billed 2nd.
PCP	Primary Care Provider / Gatekeeper who arranges for care / specialists / hospitalizations.
CHAMPVA	Insurance through government for disabled veterans.

Created by: vanstellee

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