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Commercial Ins
Commercial Insurance Terminology
| Question | Answer |
|---|---|
| Actual Charge | The charge that the physician submits for his services to the insurance carrier |
| Allowable/Approved amounts | The fee that the insurance company deems reasonable for charges that the physician submitted for services rendered |
| Capitation | system of payment used by managed care plans in which physicians are paid a fixed fee per month for each patient that is listed with that physician |
| Clearinghouse | A third party administrator that takes electronic claims and redistributes these claims to the various insurance carriers for payment |
| CMS 1500 Form (Formerly HCFA 1500) | Universal Health claim form use to report services rendered for payment by insurance carriers |
| COB-Coordination of Benefits | A program to determine which insurance carrier is the primary coverage on the patient. |
| Co-pay | Patients can either have a fixed dollar amount for their copay or they could have a percentage of the insurances allowed amount as their copay. Co-pays are in addition to any deductibles the patient may have |
| Dependent | A person, such as a spouse, child or adopted child, covered by another persons health care plan |
| Employer ID Number (EIN) | An employers Federal Tax I.D. number issued by the IRS for income tax purposes |
| Fee for Service | A method of payment in which the physician is paid for each professional service performed |
| HMO | A type of health car program in which patients receive benefits by selected providers in a network. Patient must obtain referral from their PCP to see specialist. If patient goes outside network plan may not pay. |
| Non-participating Physician | A physician who decides not to accept the determined allowable amount from an insurance plan as payment is full for his claim |
| Participating Physician | A physician who decides to sign a contract with an insurance carrier to agree to accept their payment as payment in full; less any co-pays, deductibles the patient may owe |
| PPO (Preferred Provider Organization) | Health care coverage under which patients receive services from a select group of physician. Patients typically have co-pays and out of pocket expenses. |
| Pre-authorization/Prior Authorization | Requirements in some HMO, PPO's and other health insurance plans to obtain permission for a service prior to having it performed |
| Pre-Existing Condition | A medical condition that existed before a members coverage became effective.Typiclly Insurance will not pay for this condition for the first 6 months. |
| PCP (Primary Care Physician) | A physician who oversees the care of a group of patients that are assigned to him from a manged care insurance plan-mainly HMO's & PPO's |
| Subscriber | Person is the cardholder. This person is the main member under that particular insurance coverage. |
| Tricare (CHAMPUS/CHAMVA) | An insurance plan that covers people who serve in the military or are retired from the military. |
| Workers Compensation | Insurance coverage that employers must have to cover their employees. Coverage pays for any work related injuries for the employees. Employer pays a premium for the coverage and it is State Law for the employer to carry |
Created by:
mlarke
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