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Business Pr. INS

Chapter 18/ch 16 Review of Insurances

ajudicate Determination for monetary settlement or payment
third-party payer Insurance carrier is it intervenes to be hospital or medical expenses on behalf of beneficiaries for recipients
indemity Benefits paid in a predetermined amount in the event of a covered loss
deductible Amount the insured must pay in a calendar of the school year before insurance company begins the payment of benefits
carrier Organization that offers protection against losses in exchange for premium
adjuster Employee of the Worker's Compensation insurance carrier with the case is assigned a new follows the case until it is settled
premium Periodic payment made to keep an insurance policy in force
eliminations period . Of time after the beginning of a disability for which no benefits are payable
fiscal intermediary Contractor that processes payments to providers on behalf of state or federal agencies or insurance companies
partial disability Illness or injury preventing the insured from performing one or more functions of his or her occupation
total disability Illness or injury prevent a person from performing his or her job, or any other work
permanent disability Illness or injury temporarily not allowing a person to do their job
The four main stages of the lifecycle of an insurance claim Submission, processing, adjudication, payment
What types of commercial health insurance plans MCP, self-pay, indemity
HDHP abbreviation for insurance plan w high deductible
true or false...Medicaid coverage benefits are the same across all states FALSE
true or false..each state operates its own Medicaid program True
Three Types of Tricare Standard, Extra, Prime
Medigap insurance policies are oofered by ____________ and controlled by the ______________ MCP, Government
Stark Regulation 1&2 a doc cannot refer/send a pt to another doc/facility associated w that doc who is their family
CHAMPVA is a military service benefit program for Retired and honor ably discharged no premium
an attachment to a policy excluding certain illnesses or disabilities is called waivers
birthday plan The rule most states use when a child is covered by both parent's health insurance determine primary
Elimination period is also known as the Waiting period, expected
CMS-1500 form I may only be optically scan from the original copy, uses red ink HIAA
Claim scrubber A service that receives insurance claims Addison sort them and electronically transmit them to ins companies
The standard unique help identify her that all healthcare providers use when submitting claims is called the NPI
Pre-authorization is for Medications, referrals, records,surgery
Pre-certification is for Procedures
Predetermination determines Money.. How much a service will be paid for
RBRVS Medicare
FECA Federal employee compensation act
Document that arrives from the Ins. company with insurance claim EOB, if Medicare its RA
Reasonable fee Usual, customary, justifiable
Usual fee Amount for a certain demographic
Group model HMO- individual
Staff model HMO- physician hires, pays salary
Network model HMO- plan with two or more practices
HSA FSA Tax deferred contribution
Total and partial Off job disability
Contractor processes payments to physicians on the half of state , federal MCO
The time limit for submission of a Medicare claim One fiscal year
Patient qualifies for Medicare and Medicaid is referred to as a Medi medi
And attachment to a policy excluding certain illnesses or disabilities is called a Waiver
The insured is also known as a Policyholder recipient member subscriber
Under Workmen's Comp. two terms for permanent disability Permanent and stationary, residual
AHIP government plan Americas health insurance plans
A referral where the doctor direct directly tells the patient Direct
A referral that is in writing and a letter or email Formal
A referral when the doctor calls Verbal
A referral where The patient calls the PCP Self
Oldest of pre-paid plans as a gatekeeper and yearly c apitation usually no out of network benefits HMO
Freedom of choice you know gate fee for out of network benefits usually needs pre-Certs and pre-auth PPO
Like an HMO only there is a monthly capitation as opposed to yearly IPA
IPA and HMO pays for ambulatory service PPO pay for hospital service PPG
Combination plan HMO and PPO POS
Partial and total disability by the state SDI
Temporary and permanent disability when your hurt at work Workers compensation
Participating Medicare is Contracted
Non participanting Medicare is Not contracted
Limit charge Medicare is Not contracted, urgent care
"A"Medicare covers Hospital
"B" Medicare covers Ambulatory/office visits
"C" Medicare covers Advantage plan A and B dental and vision
"D" Medicare covers Medicine
Always secondary insurance and sponsored by state local federal governments, for poor and disabled Medicaid
60% insurance pays, 40% pt pays Bronze
80% insurance pays, 20% pt pays Gold (higher premium, lower out of pocket)
70% insurance pays, 30% pt pays Silver (fair plan)
65 and older,ABCD ins, bronze silver gold plan Medicare
The term third-party pairs indicates the following are involved in healthcare reimbursement Patient provider and payer
State insurance exchanges I called market places, offer insurance based on gender age and location, or offered in every state and maybe used by all noncitizens residing in the US
The parent whose birthday falls earlier in the calendar year by month will pay for in a health care plan is part of the Birthday rule
State disability is available in California Hawaii New Jersey New York and Rhode Island
Get a workers comp case the medical assistant communicates with Adjuster
The CMS 1500 claim form has an assignment of benefits for government programs in Field 12
CMS-1500 is in red to Comply w OCR machines
When comparing electronic versus paper claim submission the average processing time is 28 to 30 days for paper and 7 to 10 days for electronic
Created by: Gmtassa23
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