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Chapter 17 Review

Allowed Charge The amount that is the most the payer will pay any provider for each procedure or service.
Birthday rule A rule that states that the insurance policy of a policyholder whose birthday comes first in the year is the primary payer for all dependents.
Clearinghouse A group that takes nonstandard medical billing software formats and translates them into the standard EDI formats.
Capitation A payment structure in which a health maintenance organization prepays an annual set fee per patient to a physician.
Coinsurance A fixed percentage of covered charges paid by the insured person after a deductible has been met.
Fee-for-service A Major type of health plan. It repays policyholders for the costs of healthcare that are due to an illness and accidents.
Dual coverage Term used for when a patient is covered by both Medicaid and Medicare.
Health maintenance organization (HMO) A healthcare organization that provides specific services to individuals and their dependents who are enrolled in the plan. Doctors who enroll in an HMO agree to provide certain services in exchange for a prepaid fee.
Fee schedule A list of the costs of common services and procedures performed by a physician.
Premium The basic annual cost of healthcare insurance.
Created by: mommyof2g