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MD300 Chapter 3plus

Review of Ch 3, 13, 14 terms

Identifies the patient to the insurance company ID number
Identifies the patient's employer group health plan Group number
A specific name assigned by the insurance company designating a specific plan for that type of insurance. plan type
Traditional insurance where reimbursement is made at 80 percent of the allowed amount and the patient pays the remaining 20 percent. Indemnity
Payment is made for each service provided. Fee for Service
Special clauses giving additional coverage over and above the standard contract. Riders
Originally provided coverage for hospital bills Blue Cross
Originally provided coverage for physician bills. Blue Shield
Indemnity plan for Blue Cross/Blue Shield ClassicBlue
Managed Care plan for Blue Cross/Blue Shield PPOBlue
Medicare Advantage plan for Blue Cross/Blue Shield SecurityBlue
Medicare Part D plan for Blue Cross/Blue Shield BlueRx
Medicare Supplemental Plan for Blue Cross/Blue Shield MedigapBlue
A Federally funded program administered by the Centers for Medicare and Medicaid - for citizens 65 and over Medicare
Pays for inpatient hospital, skilled nursing facilities, hospice care and home health Medicare Part A
Pays for doctor services, outpatient hospital, durable medical equipment Medicare Part B
The 2014 deductible for Medicare part B $147
Managed care plans and fee-for-service plans that are an alternative to original Medicare Medicare Part C
Private prescription drug plans that helps pay for prescriptions under Medicare Medicare Part D
Supplemental insurance that covers costs not reimbursed by original Medicare plan Medigap
Provides payment for health care services for eligible low income individuals Medicaid
Health insurance provided to active and retired military personnel and their dependents Tricare
Tricare members receive their care at this facility by a Tricare-contracted civilian provider Military Treatment Facility
For a premium, cardholders are eligible for a discount on medical services--it is not health insurance. Medical Discount Card
Includes financing, management, and delivery of health care services Managed Care Plan
Can be a health plan, hospital, physician group or health system Managed Care Organization
Prepaid health care; there is a pre-established payment for all health services Managed Care
Providers are prepaid monthly for members enrolled in a managed care plan; regardless of whether the patient is seen or not. Capitation
Physicians that participate in a managed care plan; they supervise health care for enrollees Primary Care Physician
Another term for a Primary Care Physician Gatekeeper
Managed Care Plans are required to meet minimum performance standards Quality Assurance
Legislation that created standards to assess managed care plans HEDIS
Assesses managed care plans; creates report cards on each plan NCQA
Assesses health care facilities JCAHO
Controls costs by reviewing the appropriateness and necessity of care prior to admission or administration of care Utilization review
Reviews the medical necessity of a procedure or service before it is done. Preauthorization
It reviews the medical necessity of any tests and procedures during hospitalization Concurrent review
Reviews the most cost-effective care after hospitalization Discharge Planning
Develops patient care plans for complicated or chronic diagnosed cases Case Management
Prevented providers from discussing all treatment options with the patient; now largely prohibited Gag clauses
Offered to physicians to encourage them to keep costs down Physician incentives
Provides services to enrolled members on a pre-paid basis Health Maintenance Organization
Medical Care sought from participating providers within a managed care plan In-network
Medical care sought from nonparticipating providers Out-of-network
Group of physicians, hospitals, and providers that offer price discounts to insurance companies in exchange for more members Preferred Provider Organization
Provides benefits if they receive services from network providers only Exclusive Provider Organization
Patients have the freedom to use HMO providers or to self-refer out to non-HMO providers for a higher fee Point of Service Plan
Provides subscribers or employees a choice of HMO, PPO, or traditional health plans Triple Option Plan
another name for Triple Option Plan Cafeteria Plan
Created by: Kirkster