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MED112 CODE/BILL
MED112 CH 01 KEY TERMS
| DEFINITION | TERM |
|---|---|
| MED112 CH 1 KEY TERMS | |
| The practice’s operating expenses, such as for overhead, salaries, supplies, and insurance. | accounts payable (AP) |
| Monies owed to a medical practice by its patients and third-party payers. | accounts receivable (AR) |
| The process followed by health plans to examine claims and determine benefits. | adjudication |
| The amount of money a health plan pays for services covered in an insurance policy. | benefit |
| Payment method in which a fixed prepayment covers the provider’s services to a plan member for a specified period of time. | capitation |
| The movement of monies into or out of a business. | cash flow |
| The recognition of a person demonstrating a superior level of skill on a national test by an official organization. | certification |
| The portion of charges that an insured person must pay for healthcare services after payment of the deductible amount; usually stated as a percentage. | coinsurance |
| Actions that satisfy official guidelines and requirements. | compliance |
| Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses. | consumer-driven health plan (CDHP) |
| An amount that a health plan requires a beneficiary to pay at the time of service for each healthcare encounter. | copayment |
| Medical procedures and treatments that are included as benefits under an insured’s health plan. | covered services |
| An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan’s payment begins. | deductible |
| The number assigned to a diagnosis in the International Classification of Diseases. | diagnosis code |
| A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual. | electronic health record (EHR) |
| Standards of conduct based on moral principles. | ethics |
| Standards of professional behavior. | etiquette |
| A service specified in a medical insurance contract as not covered. | excluded service |
| A payment method based on provider charges. | fee-for-service |
| An electronic transaction or a paper document filed with a health plan to receive benefits. | healthcare claim |
| Computer hardware and software information systems that record, store, and manage patient information. | health information technology (HIT) |
| A managed healthcare system in which providers agree to offer healthcare to the organization’s members for fixed periodic payments from the plan; usually members must receive medical services only from the plan’s providers. | health maintenance organization (HMO) |
| Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers, health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other government and nongovernment plans. | health plan |
| Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits. | indemnity plan |
| System that combines the financing and the delivery of appropriate, cost-effective healthcare services to its members. | managed care |
| Organization offering some type of managed healthcare plan. | managed care organization (MCO) |
| Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records. | medical coder |
| A written policy stating the terms of an agreement between a policy-holder and a health plan. | medical insurance |
| Medical office administrative staff member who handles billing, checks insurance, and processes payments. | medical insurance specialist |
| Payment criterion of payers that requires medical treatments to be clinically appropriate and provided in accordance with generally accepted standards of medical practice. To be medically necessary, the reported procedure or service must match the diagnosis, be provided at the appropriate level, not be elective, not be experimental, and not be performed for the convenience of the patient or the patient’s family. | medical necessity |
| A group of healthcare providers, including physicians and hospitals, who sign a contract with a health plan to provide services to plan members. | network |
| Medical procedures that are not included in a plan’s benefits. | noncovered services |
| Description of a provider who does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan’s enrollees. | out-of-network |
| Description of the expenses the insured must pay before benefits begin. | out-of-pocket |
| Contractual agreement by a provider to provide medical services to a payer’s policyholders. | participation |
| Record of all charges, payments, and adjustments made on a particular patient’s account. | patient ledger |
| Health plan or program. | payer |
| Periodic capitated prospective payment to a provider who covers only services listed on the schedule of benefits. | per member per month (PMPM) |
| A software program that combines both a PMP and an EHR into a single product. | PM/EHR |
| Person who buys an insurance plan. | policyholder |
| Business software designed to organize and store a medical practice’s financial information; often includes scheduling, billing, and electronic medical records features. | practice management program (PMP) |
| Prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered. | preauthorization |
| Managed care organization structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge. | preferred provider organization (PPO) |
| Money the insured pays to a health plan for a healthcare policy. | premium |
| Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests. | preventive medical services |
| A physician in a health maintenance organization who directs all aspects of a patient’s care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper. | primary care physician (PCP) |
| Code that identifies medical treatment or diagnostic services. | procedure code |
| For a medical insurance specialist, the quality of always acting for the good of the public and the medical practice being served. This includes acting with honor and integrity, being motivated to do one’s best, and maintaining a professional image. | professionalism |
| Person or entity that supplies medical or health services and bills for, or is paid for, the services in the normal course of business. A provider may be a professional member of the healthcare team, such as a physician, or a facility, such as a hospital or skilled nursing home. | provider |
| Transfer of patient care from one physician to another. | referral |
| All administrative and clinical functions that help capture and collect patients’ payments for medical. | revenue cycle |
| List of the medical expenses that a health plan covers. | schedule of benefits |
| An organization that assumes the risks of paying for health insurance directly and sets up a fund from which to pay. | self-funded (self-insured) health plan |
| Private or government organization that insures or pays for healthcare on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party. | third-party payer |
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