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Insurance Terms
Insurance
| Term | Definition |
|---|---|
| Private Insurance | Provided by a person's employer |
| Primary Insurance | insurance that is filed first and it 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 parents'insurance. |
| Self Insured | Individuals pay for their insurance. ( Usually for people who are self employed. |
| Self pay | People who have no coverage and would be expected to pay at a 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. An EOB also includes information that pertains to the amounts applied to the deductible, coinsurance or other allowed amou |
| Co-insurance | A percentage of the total cost that an individual must contribute toward each service (i.e.: 90% /10%, 80%/20%. The higher the premium, the lower the out -of- pocket costs throughout the year. |
| 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 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 died in service- related disabilities. |
| Medicaid | Health insurance to the medically indigent population through a cost sharing program between the 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 a work- related injury. |
| CHIP | Children's Health Insurance Program: Offers low cost health coverage for children from birth through age 18. Designed for families who earn too much 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 pay a portion of the premium and 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. |
| HMO (Health Maintenance Organization | A type of health insurance plan that usually limits coverage of care from doctors who work for or contract with the HMO. It generally won't cover out of network care except in an emergency. An HMO may require you to live or work in its service area to be |
| PPO (Preferred Provider Organization) | 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 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 in conjunction with a high deductible plan. Co |
| Flexible Spending Account (FSA) | This account is funded with the pretax dollars by an employee. Do not roll over to the next year ( funds will be lost if not used). |
| ICD-10-CM | international classification of diseases. October 1sr 2015. 55,000 more codes than the old system. Specific reporting of diseases. 3-7 characters. first character is a letter, second and third are numbers. |
| Upcoding | translates written descriptions of diseases, ailments, injuries or any health encounter into a numeric or alphanumeric code. |
| CMS-1500 form | can be submitted electronically, must be timely (12 months) must use an X. medicare only accepts capital letters. |
| Referrals | form required by insurance companies that is used when a provider wants to send a pt to a specialist. |
| Participating Provider | This means that the provider and insurance company have agreed between the amounts charged and approved and what will and will not be reimbursed. * Non-participating provider may claims all together or pay at a lower reimbursement rate. |
| Account balance | total amount owed on an account |
| Debit | an amount owed. |
| Accounts receivable | money owed to the provider |
| Accounts payable | debts incurred and not paid yet |
| Credit | a monetary balance in an individuals favor |
| Assets | the entire saleable property of a person, association, cooperation, or estate applicable/subject to the payment of debts. |
| Liabilities | amounts owed- debt |
| Electronic Medical Record (EMR)/Electronic Health Record (HER) | digital chart used in the facility. includes the EMR and other info to be used between more than one facility. |
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