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Health Insurance ?s

Medical Terminology

Health insurance is a contract between a policy holder and an insurance carrier
group insurance a group of employees and their dependents are insured under 1 group policy issued to the employer
personal insurance an insurance plan issued to an individual
pre-paid health plan pre-determined set of benefits covered under one set annual fee
health maintenance organization (HMO) a managed care benefits plan that provides a wide range of medical services to idividuals enrolled - must have a primary care physician
preferred provider organization (PPO) like a HMO, but more flexiable - pay higher premiums - no primary care physician
point-of-service plan (POS) managed care plan that gives beneficiaries the option whom to see for services.
Medicare Part A covers hospital and hospice care
Medicare Part B covers medical expenses for Dr visits and lab tests
Medicare Part D covers prescription drugs
advance beneficiary notice a document provided to a medicare beneficiary by a provider prior to service being rendered letting the beneficiary know of their responbility to pay if medicare denies the claim
medigap (medicare supplemental insurance) this covers medical services that medicare denies (coinsurance)
blue cross covers hospital services
blue shield covers physician services
assignment of benefits reimbursement is directly sent from payer to the provider
accept assignment the provider agrees to accept what the insurance company approves as payment in full
fee-for-service a fee that is charged for each procedure or service performed by the physician
fiscal intermediary an insurance company that bids for a contract with CMS to handle the Medicare program in a specific area
premium the cost of insurance coverage
deductible out of pocket amount that must be paid annually
coinsurance percentage of cost of the covered services that a policyholder or a secondary insurance pays
co-payment a cost sharing requirement for the insured to pay at the time of service
coding the process of converting diagnoses, procedures and services into numeric and alphanumeric characters
exclusions and limitations conditions, situations and services NOT covered by the insurance
pre-certification to determine the patient's benefits and the maximum dollar amount that the insurance company will pay
pre-authorization a requirement for some health insurance plans to obtain permission for a service or procedure before it is done
qualified diagnosis a working diagnosis which is not yet established
eligibility the qualifying factor or factors that must be met before a patient receives benefits
coordination of benefits (COB) when 2 insurance companies work together to coordinate payment of the benefits
peer review organization (PRO) a state based group of physicians working under government guideline to review cases and determine their appropriateness and quality of professional care
civil monetary penalties law (CMPL) law passed by the federal government to prosecute cases of medicaid fraud
remittance advice an electronic or paper-based report of payment by the payer to the provider
patient's bill of rights developed to promote the interests and well being of the patients and residents of the health care facility
Created by: 540802871