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Private Insurance Provided by a person's employer
Primary Insurance Insurance that is filed first and is the main insurance for a person
Premium The amount of money that a person pays for their insurance
Secondary Insurance Double coverage
Self Insured Individual pays for their insurance
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 individual.
Government Plans Special programs by state and federal government that provides insurance for the elderly, indigent, and for children Medicare, Medicaid, Tricare, CHAMPVA
Co-pay A specified sum of money based on the patient's insurance policy benefits due at the time of service
Deductable 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 included information that pertains to the amount applied to the deductible, co-insurance 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 provider from insurance carrier. Similar to 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 and older Part A (hospitalization), Part B (routine office visits), Part D prescription coverage)
Tricare Authorize 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 federal government and states. Cover 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
CHIP Offers low-cost health coverage for children from birth through age 18. Designed for families who earn too much to qualify 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 employee's pay
Individual Policies Insurance plans that an individual funds themselves. Patient 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 HMO. Generally won't cover out-of-network care except in an emergency. HMO may require you to live or work its service area to be eligibility
PPO (Preferred Provider Organization) Medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced rates.
Health Saving Account (HAS) Saving Account that can be used to pay for medical expenses. Funds are not taxed until time of withdrawal. Any amount not used stays in account and accrues interest after a year. Must be used in conjunction with 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 Procedure coding system comprised of medical classifications for procedural codes. Typically used in hospitals that record various health treatments and tests
Upcoding Billing for more expensive service than the one actually performed
CMS-1500 form Claim form sent to insurance company for review and payment Divided into sections and block must be filled out correctly
Referrals Document or form required by insurance companies that is used when a provider wants to send a patient to a specialist
Participating Provider Provider and insurance company have agreed between the amounts charges and approved and 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
Account Payable Debts incurred and not yet paid
Credit Monetary balance in an individual's favor
Assets Entire salable property of a person, association, corporation or estate applicable or subject to the payment of debts
Liabilities Amount; debt
Electronic Medical Record (EMR)/ Electronic Health Record (HER) Digital chart that is used in the facility (EMR) Includes the EMR and other information to be used between more than one facility (EHR)
Created by: 278523
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