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MBY150 Yellow
HIT Chapter 6 Vocabulary
| Question | Answer |
|---|---|
| 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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