Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
MA CH09 H1E
| Question | Answer |
|---|---|
| policy | a course of action that should be taken every time a certain situation occurs. |
| benefits | in the insurance industry, the services or items covered in an insurance policy. |
| claim | in the insurance industry, a request for payment of covered benefits. |
| dependent | in health insurance, an individual who receives insurance benefits due to a relationship to the subscriber (e.g., a child or spouse). |
| guarantor | in health care, the person who is financially responsible to pay a medical bill. |
| premium | in the insurance industry, a monthly payment made to purchase insurance coverage. |
| deductible | in the insurance industry, an amount that must be paid for covered services by the subscriber before insurance benefits are paid. |
| copayment | in healthcare insurance, a set amount that must be paid by the subscriber for a covered service. |
| coinsurance | in healthcare insurance, a percentage of charges that must be paid by the subscriber for a covered service. |
| Patient Protection and Affordable Care Act (ACA) | a federal law enacted in 2010 with the goals of making insurance affordable to more people, expanding Medicaid coverage, and supporting care practices that improve patient health and lower costs. |
| out-of-pocket maximum | in healthcare insurance, a limit on the total amount a subscriber must pay each year for covered services; after the subscriber meets the out-of-pocket maximum, the insurer must pay 100% of covered costs. |
| explanation of benefits (EOB) | a summary of coverage provided by an insurer to the subscriber and the healthcare provider after an insurance claim is made, including what portion of the charges are covered by insurance and what portion must be paid by the patient. |
| remittance advice (RA) | statement a document provided by an insurer to a healthcare provider summarizing a health insurance claim, including charges that have been billed, what portion are covered by insurance, and what portion must be paid by the patient. |
| allowable amount | a standard fee for a treatment, service, or supply set by an insurer; providers contracted with an insurer are obliged to accept this amount as payment. |
| rider | something added to an insurance policy that changes the terms of the policy, for example to add specific additional coverage. |
| indemnity plan | type of health insurance which subscriber can chose any provider or facility for health care and receive reimbursement based on billed costs as long as the charges are considered usual, customary, and reasonable; sometimes called a fee-for-service plan. |
| managed care | a system or strategy of managing health care in a way that controls costs. |
| gatekeeper | term sometimes used to describe a primary care provider; refers to the provider’s role in managing a patient’s access to healthcare services. |
| health maintenance organization (HMO) | a form of health insurance in which the cost of care is covered only when a person uses a particular doctor or group of doctors except in case of emergency; seeing specialists generally requires referrals from a primary care provider. |
| capitation fee | a form of managed care payment in which a provider receives a flat fee for each patient each month rather than receiving payment for each service provided. |
| preferred provider organization (PPO) | a managed care plan in which patients are encouraged, but not required, to see providers in a provider network established by the insurance carrier. |
| exclusive provider organization | a type of managed care plan that requires the patient to see network providers for all health services. |
| point-of-service plan | a type of managed care plan that requires the patient to choose a primary care provider and see specialists in the provider network with a referral; patients may see providers outside the network but will pay more to do so. |
| Medicare | a federal health insurance program for people who are 65 or older, have certain disabilities or permanent kidney failure, or are ill and cannot work. |
| Medicare Administrative Contractors (MACs) | private insurers contracted to manage Medicare claims in a specific geographical region. |
| Medicaid | a medical assistance program for people who have a low income, as well as for people with disabilities. |
| Children’s Health Insurance Program (CHIP) | a government program providing low-cost health insurance to families and pregnant women with a low income. |
| TRICARE | the health insurance program of the US military. |
| primary insurance | the first insurer to pay benefits when a patient is covered by more than one policy. |
| secondary insurance | in cases in which a patient is covered by more than one insurance policy, the insurer that pays on the remaining balance after the primary insurance benefits have been paid. |
| coordination of benefits (COB) | determination of how a claim should be paid when more than one insurer covers a patient. |
| assignment of benefits | permission granted by a subscriber for insurance benefits to be paid directly to a provider for services provided. |
| National Provider Identifier (NPI) | a 10-digit number unique to each healthcare provider and used in the filing of insurance claims. |
| direct billing | in health care, an arrangement in which a provider or facility submits claims directly to an insurer on behalf of a patient. |
| clearinghouse | a company that specializes in reviewing insurance claims for errors and submitting claims to insurers on behalf of a provider/facility. |
| Advance Beneficiary Notice (ABN) | a Medicare form used to inform a patient that a procedure or service will not be covered by Medicare benefits and that the patient is financially responsible if the service is provided. |
| International Classification of Diseases (ICD) | a coding system used to track morbidity and mortality; the basis of coding systems used to identify diagnoses and inpatient procedures for insurance purposes. |
| billable | in health care, a code with adequate detail to present to an insurer as part of a claim. |
| encounter | in health care, an interaction between a patient and a provider that may be billed/generate an insurance claim. |
| CPT code | a code established in the American Medical Association’s Current Procedural Terminology manual, which is the standard coding set used to bill insurers for most outpatient care. |
| bundled code | a code used to submit an insurance claim for two or more procedures that frequently occur together. |
| Healthcare Common Procedure Coding System (HCPCS) | an additional coding system for procedures, services, equipment, and supplies not included in the CPT manual. |
| downcode | in HC coding, refers to provider submitting claim using a code for a lower level of service than what was provided, or to insurer paying claim at lower rate than submitted code would require (i.e. if insurer believe code submitted wasn't justified). |
| upcode | in healthcare coding, inappropriately billing for a procedure or service that is more complex than what was performed or provided. |
| audit | in healthcare billing, a review of diagnosis and procedure codes to ensure that they follow the correct guidelines; may be performed internally for quality assurance, or externally as a form of inspection. |
Created by:
cvis
Popular Medical sets