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Health Insurance
Treams
| Term | Definition |
|---|---|
| • Advance beneficiary notice (ABN) | also known as a waiver of liability, is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service. |
| • Allowed amount | a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate. |
| • Assignment of benefits | An arrangement by which a patient requests that their health benefit payments be made directly to a designated person or facility, such as a physician or hospital. |
| • Authorization to release medical | A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. |
| information (release of medical information form) | is a document that gives healthcare professionals permission to share patient medical information with other parties. ... If you are ever instructed to share healthcare information on behalf of a patient, make sure you have them sign a release form. |
| • Beneficiary | A person eligible for or receiving benefits under an insurance policy or plan, such as Medicare or Medicaid programs. |
| • Capitation | the payment of a fee or grant to a doctor, school, or other person or body providing services to a number of people, such that the amount paid is determined by the number of patients, students, or customers. |
| • Carrier | An entity that may underwrite or administer a range of health benefit programs. ... Claim: A claim is a request for payment for services and benefits received. |
| • CMS-1500 | the standard claim form designed by the Centers for Medicare and Medicaid Services to submit physician ser-vices for third-party (insurance companies) payment; the standard paper claim form to bill Medicare Fee-For-Service (FFS) Con-tractors when a paper |
| • Coinsurance | a type of insurance in which the insured pays a share of the payment made against a claim. |
| • Coordination of benefits (COB) | allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary payment responsibility and the extent to which the other |
| • Co-payment | a payment made by a beneficiary (especially for health services) in addition to that made by an insurer. |
| • Deductible | able to be deducted, especially from taxable income or tax to be paid. "child-care vouchers will be deductible expenses for employers" |
| • Explanation of benefits | a printed description of the benefits provided by the insurer to the benefi-ciary; provides information to the patient about how an insurance claim from a health provider (such as a physician or hospital) was paid on his or her behalf. |
| • Fee schedule | is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. |
| • Gatekeeper | one who regulates access to someone or something; in insurance, a primary care physician who coordinates the patient’s referral to specialists and hospital admissions. |
| • Medigap | is Medicare Supplement Insurance that helps fill "gaps" in. Original Medicare. and is sold by private companies. Original Medicare pays for much, but not all, of the cost for covered health care services and supplies. |
| • Member | a person, country, or organization that has joined a group, society, or team. |
| • Nonparticipating provider | is a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. |
| • Participating provider | is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis. |
| • Patient status | code is a two-digit code that identifies where the patient is at the conclusion of a health care facility encounter or at the end of a billing cycle (the 'through' date of a claim). ... |
| • Precertification | A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. |
| • Preexisting condition | is a medical condition that started before a person's health insurance went into effect. |
| • Preferred provider organization (PPO) | type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. |
| • Premium | is an amount paid periodically to the insurer by the insured for covering his risk. Description: In an insurance contract, the risk is transferred from the insured to the insurer. |
| • Real time adjudication (RTA) | as the ability for a payer gateway to receive, validate, pre-process, adjudicate and respond to the submitter of a claim (837) with a Page 2 final, binding decision on the claim – in less than 30 seconds. |
| • Waiver | an act or instance of waiving a right or claim. |
Created by:
blue2998
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