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insurance
| Question | Answer |
|---|---|
| Health insurance | A plan that helps pay for medical expenses |
| PPO (Preferred Provider Organization) | A health insurance plan that allows patients to see in-network or out-of-network providers without a referral |
| HMO (Health Maintenance Organization) | Requires patients to choose a primary care provider (PCP) and usually requires referrals to see specialists |
| POS (Point of Service) | Combines features of HMO and PPO; requires a PCP but allows some out-of-network care |
| EPO (Exclusive Provider Organization) | No referrals required, but generally covers only in-network providers except in emergencies |
| Medicare | Federal health insurance for people age 65 and older and certain younger people with disabilities |
| Medicaid | State and federal health insurance for eligible low-income individuals and families |
| Copayment (Copay) | A fixed amount the patient pays for a healthcare service |
| Deductible | Amount the patient pays before insurance begins paying |
| Coinsurance | Percentage of costs the patient pays after meeting the deductible |
| Premium | Monthly amount paid to keep insurance coverage active |
| Explanation of Benefits (EOB) | Statement explaining what insurance paid and what the patient may owe |
| Preauthorization (Prior Authorization) | Approval required from insurance before certain services or procedures |
| Subscriber | person who holds the insurance policy |
| Dependent | person covered under another person's insurance plan (such as a child or spouse) |
| Beneficiary | person who receives benefits from an insurance plan |
| Guarantor | person financially responsible for the patient's bill |
| What code describes a diagnosis? | ICD-10-CM |
| What code describes a procedure? | CPT |
| Who completes the CMS-1500 form? | Healthcare provider's office/billing staff |
| ICD-10-CM | codes used to describe diagnoses and medical conditions |
| CPT | codes used to describe medical procedures and services performed by providers |
| HCPCS | codes used for supplies, equipment, medications, and services not included in CPT |
| Medical Necessity | requirement that a service must be appropriate and needed for diagnosis or treatment |
| Coordination of Benefits (COB) | process of determining which insurance pays first when a patient has multiple plans |
| Denied Claim | claim rejected by insurance due to errors, lack of coverage, or missing information |
| Clean Claim | claim submitted correctly with all required information |
| Fraud | intentional deception for financial gain |
| Abuse | improper practices that may result in unnecessary costs |
| Medicare Part A | hospital insurance (inpatient hospital care, skilled nursing, hospice) |
| Medicare Part B | medical insurance (physician visits, outpatient services, preventive care) |
| Medicare Part C (Medicare Advantage) | private insurance alternative to Original Medicare |
| Medicare Part D | prescription drug coverage |
| Subscriber | person who holds the insurance policy |
| Dependent | person covered under another person's insurance plan (such as a child or spouse) |
| Beneficiary | person who receives benefits from an insurance plan |
| Guarantor | person financially responsible for the patient's bill |
| What does EOB explain? | Insurance payment details and patient responsibility |
| Which Medicare part covers physician visits? | Medicare Part B |
Created by:
Valentine.Taylor