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HIT Chapter 6 Vocabulary

Administrative Services Organization (ASO) A person or organization that handles a wide variety of health insurance administrative services for organizations that have chosen to self-fund their health benefits
Autonomy freedom to choose what medical expenses will be covered
Basic Health Insurance plan that includes hospital room and board, inpatient hospital care, some hospital services and supplies, surgery, and some physician visits.
BlueCard program plans that allow members and their families to obtain healthcare services while traveling or working anywhere in the United States
BlueCard worldwide allows members and their families to receive inpatient and outpatient coverage at no additional cost in more than 200 foreign countries
Blue Cross and Blue Shield Federal Employee Program (FEP) largest employer-sponsored group health insurance program in the world; allows eligible members to have access to various types of plans including FFS, PPO, POS, and HMO.
Coinsurance percentage of healthcare expenses
Commercial Health Insurance also known as private insurance; any kind of health insurance paid by someone other than the government
Comprehensive Insurance plan that combines the coverage of basic health and major medical insurance plans
Covered expenses charges incurred that qualify for reimbursement under the terms of the policy contract
Deductible yearly out of pocket payments made by the patient before the health insurance carrier begins to contribute
Explanation of Benefits (EOB) also known as a remittance advice; document prepared by the carrier that gives details of how the claim was adjudicated
Federal Employee Health Benefits Program (FEHB) government health insurance program that provides coverage for its own civilian employees
Fee-for-service (FFS)/Indemnity plan traditional type of healthcare that offers the most choices of providers and in which patients can choose any provider they want and change providers at any time
Fiscal intermediary a commercial insurer that contracts with the DHHS for the purpose of processing and administering Part A Medicare claims for reimbursement of health coverage.
Group Insurance a contract between an insurance company and an employer that covers eligible employees or members
Healthcare Service Plans Individual BCBS plans throughout the United States that each has specific guidelines for completing the CMS-1500 which vary from plan to plan
Health insurance policy premium a standard monthly or quarterly fee for insurance plan coverage
Health Maintenance Organization (HMO) plan that provides healthcare to its enrollees from specific physicians and hospitals that contract with the plan
Insurance cap the amount of money the policyholder has to pay out of pocket for any one incident or in any one year
Lifetime maximum cap amount after which the insurance company would not pay any more of the charges incurred
Major medical insurance plan that covers treatment for long, and high-cost illnesses or injuries, as well as, Inpatient and Outpatient expenses
Managed Care Plan plan that typically involves the financing, managing, and delivery of healthcare services and is composed of a group of providers who share the financial risk of the plan or who have an incentive to deliver cost-effective, but quality, service.
Medicare supplement plans plans designed to provide coverage for some of the costs that Medicare does not pay;such as deductibles, coinsurance, and noncovered services.
Nonforfeitable interest amount of pension employees do not give up when quitting or retiring
Participating Provider (PAR) a provider who signs a contractual arrangement with a third-party insurance contractor and agrees to accept the amount paid by the carrier as payment in full
Point-of-service plan (POS) also referred to as an open ended HMO; plan allows members to use the HMO provider or go outside of the plan for a higher out of pocket expense
Policyholder the individual in whose name the policy is written
Preferred provider organization (PPO) a network of physicians that provide medical services at a discount to the individuals who participate in the PPO
Reasonable and customary fee fee charged by the provider that falls within the parameters of the fee commonly charged for that particular service within a specific geographic area
Self-insured/self-insurance plan where the employer is responsible for the cost of its employees medical services
Single or Specialty service plans health plans that provide services only in certain health specialties, such as mental health, vision, or dental plans
Stop Loss Insurance protection from the devastating effect of exorbitant medical claims resulting from prolonged and intense medical services due to catastrophic illness or injury
Supplemental coverage another example of single or specialty coverage. Add-on coverage such as vision, dental, or prescription drug coverage
Third-party payer any organization that provides payment for specified coverages provided under the health plan
Third-party administration(TPA) person or organization who processes claims and performs contractual administrative services
Created by: Alyshia
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