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Blesi8e Ch27 Terms
[MO2] Health Insurance [Tier 01]
| Term | Definition |
|---|---|
| accept assignment | provider agrees to accept the insurer's payment as payment in full for the service provided |
| advance beneficiary notice (ABN) | document used to notify a Medicare beneficiary that it is unlikely or certain that Medicare will not pay for the service they are going to be provided and that they will be responsible for payment |
| allowed amount | the maximum amount oan insurer will pay for any given service``` |
| assignment of benefits | the authorization, by a patient, for payment to be made directly by the patient's insurance to the provider for services |
| beneficiary | person entitled to benefits of an insurance policy |
| birthday rule | a means to identify primary responsibility in insurance coverage; when children have coverage through more than one parent, the parent with the birthday earliest in the year, month and day is identified as the primary insurer |
| capitation | the health care provider is paid a fixed amount per member, per month for each patient who is a member of a particular insurance organization |
| carrier | the company that provides the policy |
| coinsurance | a percentage that a patient is responsible for to pay for each service AFTER the deductible has been met |
| conversion factor | the dollar amount that converts the Relative Value Units (RVU) into a fee |
| coordination of benefits (COB) | the policy provision that limits benefits to 100 percent off the cost: also known as dual coverage |
| co-payment | a specified amount the insured must pay toward the charge for professional services rendered at the time of service |
| deductible | an amount to be paid before insurance will pay |
| dependent | person covered under a subscriber's insurance policy |
| diagnosis-related group (DRG) | method of determining reimbursement from medical insurance according to diagnosis on a prospective basis |
| exclusive provider organization (EPO) | patients must use their EPO's provider network when receiving care |
| explanation of benefits | a printed description of the benefits provided by the insurer to the beneficiary |
| fee-for-service | payment for each service that is provided |
| fee schedule | a list of predetermined payment amounts for profession services provided to patients |
| flexible spending arrangement (FSA) | pretax funds set aside for use in payment of medical services and supplies not covered by insurance |
| gatekeeper | a primary care physician who coordinates the patient's referral to specialists and hospital admissions |
| geographic practice cost index (GPCI) | A scale defined by Medicare based on the relative costs of practicing medicine in specific geographic location |
| health maintenance organization (HMO) | group insurance that entitles members to services provided by participating hospitals, clinics and providers |
| health reimbursement arrangement (HRA) | a plan set up by an employer to cover medical expenses for its employees |
| health savings account (HSA) | a tax sheltered savings account, with contributions from the employer and employee, which can be used to pay for medical expenses |
| indemnity plan | compensation for damage done or loss caused |
| independent practice association (IPA) | an organization that contracts with independent physicians and provides services to managed care organization on a negotiated per capita rate, flat retainer fee or negotiated fee-for-service basis |
| medicare | a federal program for providing health care coverage for individuals over the age of 65 or those who are disabled |
| medicaid | a joint funding program by federal and state governments for the medical care of low-income patients on public assistance |
| medigap | private insurance to supplement Medicare benefits for payment of the deductible, co-payment and coninsurance |
| preauthorization | prior approval of insurance coverage and necessity of procedure |
| precertification | obtaining plan approval for service prior to the patient receiving them |
| predetermination | the discovery of the maximum amount of money the carrier will pay for primary surgery, consultation service, postoperative care and so on |
| preferred provider organization (PPO) | an organization of physicians who network together to offer discounts to purchasers of health care insurance |
| primary | occurring first in time, development or sequence |
| quality assurance | inclusive policies, procedures and practices as standards for reliable laboratory results |
| secondary | one step removed from the first; not primary |
| subscriber | the person who has been insured; an insurance policy holder |
| third-party reimbursement | a phrase coined to indicate payment of services rendered by someone other than the patient |
| third-party liability (TPL) | the legal obligation of third parties to pay part or all of the expenditures for medical assistance furnished under a state plan |
| utilization review | an evaluation of health care services to determine the medical necessity, appropriateness and cost-effectiveness of the treatment plans for a given patient |
| waiver | to give up; forego |
Created by:
MaesterRay
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