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Insurance Terms
By Abby Hernandez R CMA 1/2
| Term | Definition |
|---|---|
| Private Insurance | Healthcare coverage provided by a private company, not the government |
| Primary Insurance | Insurance company responsible for paying the claim first |
| Premium | Amount of money an individual or business pays for an insurance policy |
| Secondary Insurance | The second health plan when you have more than one health insurance plan |
| Self Insured | Acting as your own insurance company to cover your own losses |
| Self pay | Allows customers to pay for goods or services without assistance |
| Government Plans | A plan established and maintained for its employees by the Government of the United States, by the government of any State or political subdivision |
| Co-pay | A fixed out-of-pocket amount paid by an insured for covered services |
| Deductibles | A specified amount of money that the insured must pay before an insurance company will pay a claim |
| Explanation of benefits (EOB) | Is the insurance company’s written explanation regarding a claim, showing what they paid and what the patient must pay |
| Co-insurance | A type of insurance in which the insured pays a share of the payment made against a claim |
| Remittance advice (RA) | Is a document that provides essential information about your claim payments |
| Advance beneficiary notice (ABN) | Patients make informed decisions about items and services Medicare usually covers but may not in specific situations |
| Medicare | A federal system of health insurance for people over 65 years of age and for certain younger people with disabilities |
| Tricare | TRICARE is the uniformed services health care program for active duty service members |
| CHAMPVA | It covers vision benefits for diabetes patients only. Dental benefits are limited. For most care, including medical screening, mental health, emergency room, hospital stay, ambulance, vaccinations, office visits |
| Medicaid | A federal system of health insurance for those requiring financial assistance |
| Worker’s Compensation | a government-mandated program that provides benefits to workers who become injured or ill on the job or as a result of the job |
| CHIP | If your children need health coverage, they may be eligible for the Children's Health Insurance Program |
| Group Policies | Provide coverage to a group of members, usually comprised of company employees or members of an organization |
| Individual Policies | Individual health insurance is coverage that you purchase on your own, on an individual or family basis, as opposed to obtaining through an employer or from a government-run |
| HMO (Health Maintenance Organization | An HMO is a health insurance plan that contracts with a network of physicians, hospitals and medical specialists |
| PPO (Preferred Provider Organization) | Health insurance plan for individuals and families |
| Health Savings Account (HAS) | Tax-advantaged personal savings account |
| Flexible Spending Account (FSA) | Is a special account you put money into that you use to pay for certain out-of-pocket health care costs |
| ICD-10-CM | Is a tool that assigns codes for diseases, symptoms, abnormal findings, and external causes of a disease or injury |
| Upcoding | Upcoding occurs when a healthcare provider has submitted codes for more severe conditions than diagnosed for the patient to receive higher reimbursement |
| CMS-1500 form | Standard claim form |
| Referrals | Authorization or permission from your insurance plan for treatment with a specialist provider issued by a PCP |
| Participating Provider | A participating provider is a healthcare provider that has agreed to contract with an insurer or managed care plan to provide eligible services to individuals covered by its plan. |
| Account balance | If there is still a balance owed on that bill and the healthcare provider or hospital expects you to pay that balance, you’re being balance billed |
| Debt | The face amount of the policy does not exceed a stated amount |
| Accounts receivable | Invoices or reimbursements owed to a medical practice, hospital or other healthcare organization |
| Accounts payable | In healthcare refers to the aggregate of money owed by the health care practice or hospital to its suppliers and employees |
| Credit | A type of credit insurance offered by lenders that provides coverage for your debt in the event |
| Assets | Valuable resources and advantages that a healthcare organization possesses |
| Liabilities | In financial accounting, a liability is a quantity of value that a financial entity owes |
| Electronic Medical Record (EMR)/Electronic Health Record (HER) | Are often used interchangeably. An EMR allows the electronic entry, storage, and maintenance of digital medical data. EHR contains the patient's records from doctors and includes demographics, test results, medical history, history of illness |
Created by:
abbyhern11
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