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Insurance
| Term | Definition |
|---|---|
| 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) |
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