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SBGR ALH 151 Week 4 Ch 17 Pearson's (2012 EK)

benefit period period of time for which payments for insurance are available
capitation rate predetermined amount paid to provider every month regardless of the number of times the patient is seen within the month
claim written and documented request for reimbursement of an eligible expense under an insurance plan
closed-panel HMO facility that is owned by the HMO and in which the providers are employees of the HMO
coordination of benefits (COB) procedures to prevent duplication of payment by more than one insurance carrier; who pays first
crossover claim patient claim that is eligible for both Medicare and Medicaid; also known as Medi/Medi
deductible amount of eligible charges each patient must pay each calendar year before the insurance plan begins to pay benefits
exclusive provider organizations (EPOs) combination of PPO and HMO concepts that allows the patient to select from a defined panel of providers
fee-for-service set of fees for services established by a health care provider and paid for by the patient
fee schedule schedule of the amount paid by a specific insurance company for each procedure or service subject to the managed care contract
formulary specific to each insurance carrier, a list of medications that will be covered under that insurance plan
gatekeeper a primary care provider who refers patients to other providers for services he or she cannot perform
health maintenance organization (HMO) managed care plan in which a range of health care services provided by a limited group of providers (such as specified physicians or hospitals) are made available to plan members for a predetermined fee
integrated delivery system (IDS) an arrangement in which provider sites have contracts with an insurance company
medical foundation a nonprofit integrated delivery system
open-panel HMO HMO in which health care providers are not employees of the HMO and do not belong to a medical group owned by the HMO
point-of-service plan (POS) insurance plan in which a patient may choose an HMO or a non-HMO provider but must pay a deductible for using a non-HMO provider
preauthorization requirement to obtain prior approval for surgery and other procedures from the insurance carrier in order to receive reimbursement
preferred provider organization (PPO) an insurance arrangement that requires the patient to use a provider under contract to the insurance company, which reimburses the provider at a discounted fee
premium amount paid for insurance
prepaid plan group of physicians or other health care providers who have a contractual agreement to provide services to subscribers on a negotiated fee-for-service or capitated basis; also known as managed care plan
primary care provider (PCP) gatekeepers provider who refers patients to other providers for services he or she cannot perform
referral the process of sending a patient to or from another physician
self-referral occurs when a patient chooses to see an out-of-network provider without authorization
Created by: SBGrandRapids