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Insurance Terms
| Term | Definition |
|---|---|
| Private Insurance | Provided by a person's employer |
| Primary Insurance | Insurance that is filed and is the main insurance for a person |
| Premium | The amount of money that a person pays for their insurance |
| Secondary Insurance | Double coverage (ex. your work and your parent's insurance) |
| Self Insured | Individual pays for their insurance (usually for people who are self employed) |
| Self Pay | People who have no coverage and would be expected to pay at the time of service. Some places will offer special pricing for self paying individuals |
| Government Plans | Special programs by state and federal government that provides insurance for the elderly, indigent, and for children |
| Co-pay | A specified sum of money based on the patient's insurance policy, benefits due at the time of service |
| Deductibles | A specific amount of money a patient must pay out of pocket before the insurance carrier begins paying for services. Deductible amounts are usually on a calendar year accrual basis |
| Explanation of Benefits (EOB) | Provided to the patient by the insurance company as a statement that details what services were paid, denied, or reduced in payment. Also includes information that pertains to the amounts applied to the deductible, coinsurance, or other allowed amounts. |
| Co-insurance | A percentage of the total cost that an individual must contribute toward each service |
| Remittance Advice (RA) | An EOB sent to the provider from the insurance carrier. Is similar to the EOB, the RA contains multiple patients and providers. Also includes the electronic funds transfer information or a check for payment. |
| Advance Beneficiary Notice (ABN) | A form that a Medicare patient will sign when the provider thinks Medicare won't pay for a specific service or item. |
| Medicare | Patients 65 years or older for Part A (hospitalization), Part B (routine office visits), Part D (prescription coverage) |
| Tricare | Authorizes dependents of military personnel to see civilian practitioners |
| CHAMPVA | Covers surviving spouses and dependent children of veterans who have died in service-related disabilities |
| Medicaid | Health insurance to the medically indigent population through a cost sharing program between federal government and states. Covers women of child bearing age and children. |
| Worker's Compensation | A state legislative law that protects employees against the cost of medical care resulting from a work-related injury |
| Children's Health Insurance Program (CHIP) | Offers low-cost health coverage for children from birth through age 18. Designed for families who earn too much money to qualify for Medicaid, but cannot afford to buy private health coverage. $35-$50/year |
| Group Policies | Offered through an individual's employer who will usually pay a portion of the premium and then deduct the remainder of the premium from the employee's pay. |
| Individual Policies | Insurance plans that an individual funds themselves. Patients might pay the entire premium themselves if they are self-employed |
| Health Maintenance Organization (HMO) | A type of health insurance plan that usually limits coverage of care from doctors who work for or contract with the HMO. Generally won't cover out-of-network care except in an emergency. May require you to live or work in its service area to be eligible |
| Preferred Provider Organization (PPO) | A medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced rates. PPO medical and healthcare providers are called preferred providers. |
| Health Savings Account (HSA) | A savings account that can be used to pay for medical expenses. These funds are not taxed until the time of withdrawal. Any amount not used stays in the account and accrues interest after a year. This must be used with a high deductible plan. |
| Flexible Spending Account (FSA) | This account is funded with pretax dollars by an employee. Do not roll over to the next year (funds lost if not used) |
| ICD-10-CM | International Classification of Diseases, Contains approx. 55,000 more codes than the previously used ICD-9-CM system, allows for reporting of disease and newly recognized conditions, allows for specificity and laterality of coding for payment |
| Upcoding | Using billing codes that reflect a more severe illness than actually existed or a more expensive treatment than was provided |
| CMS-1500 Form | This is the claim form that is sent to the insurance company for review and payment, is divided into sections and blocks that must be filled out correctly |
| Referrals | A document or form required by insurance companies that is used when a provider wants to send a patient to a specialist |
| Participating Provider | This means that the provider and the insurance company have agreed between the amounts charged and approved what will and will not be reimbursed. |
| Account Balance | The total amount owed on an account |
| Debit | An amount owed |
| Accounts Receivable | Money owed to the provider |
| Accounts Payable | Debts incurred and not yet paid |
| Credit | A monetary balance in an individual's favor |
| Assets | The entire saleable property of a person, association, corporation or estate applicable or subject to the payment of debts |
| Liabilities | Amounts owed; debts |
| Electronic Medical Record (EMR) | This is a digital chart that is used in the facility |
| Electronic Health Record (EHR) | This includes the EMR and other information to be used between more than one facility |
Created by:
MollyBibiano
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