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Insurance Terms
| Term | Definition |
|---|---|
| Private Insurance | Provided by persons 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 (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 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 |
| Co-pay | Specified some of money based on the patients insurance policy benefits due at the time of service |
| Deductibles | 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 atient 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 amoun |
| Co-insurance | A percentage of the total cost that an individual must contribute toward each service (I.e.: 90%/10%, 80%/20%) |
| 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 wont pay for a specific service or item. |
| Medicare | Patients 65 years and 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 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 form 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 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 employees' 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 | Type of health insurance plan that limits coverage of care from doctors who work for or contract with HMO. Won't cover out of network care except in an emergency. HMO may require you to live or work in it's service area to be eligible for coverage |
| PPO (Preferred Provider Organization) | Medical care arrangement which medical professional & facilities provide services to subscribed clients at reduced rate. PPO medical & healthcare providers are called preferred providers |
| Health Savings Account (HSA) | Saving account used to pay medical expenses. Funds not taxed until time of withdrawal. Amount not used stays in account and accrues interest after a year. Must be used in conjunction with a high deductible plan. Contributions can be made by individual/ e |
| Flexible Spending Account (FSA) | Account funded with pretax dollars by an employee. (Do not roll over to the next year fund-lost if not needed) |
| ICD-10-CM | International classification of diseases. Allows specific reporting of diseases and newly recognized conditions |
| Upcoding | When a healthcare provider submits codes to Medicare, Medicaid, or private insurers for more serious (and more expensive) diagnoses or procedures than the provider actually diagnosed or performed |
| CMS-1500 form | Claim form sent to insurance company for review and payment which is divided into sections and blocks that must be filled out correctly |
| Referrals | Document or form required by insurance companies that is used when provider wants to send a patient to specialist |
| Participating Provider | Provider and the insurance company have agreed between the amounts charged and approved what will and will not be reimbursed |
| Account Balance | Total amount owed on an account |
| Debit | An amount owed |
| Accounts receivable | Money owed to provider |
| Accounts payable | Debts incurred and not yet paid |
| Credit | Monetary balance in individuals favor |
| Assets | Entire saleable property of a person, associations, corporation or estate applicable or subject to the payment of debts |
| Liabilities | Amounts owed; debt |
| Electronic Medical Record (EMR)/Electronic Health Record (HER) | Digital chart that is used in the facility, EHR includes EMR and other other information to be used between more than one facility |
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