Term | Definition |
Allowable | Maximum amount of money that many third-party payers allow for a specific procedure/service |
Actual charge | Charge the physician submits for his services to the insurance carrier |
Authorization | Number given by the insurance company authorizing approval of a procedure/service. Does not guarantee payment |
Beneficiary | Person entitled to receive benefits from an insurance policy |
Birthday Rule | Insurance rule-when an individual is covered under two insurance policies, the policy holder whose birthday comes first in the calendar year, month and day- not year- is primary/first payer |
Capitation | Payment used by managed care plans; fixed payment is reimbursed to the provider for patients enrolled under his/her name |
Carrier | Insurance companies that provide the policy and benefits |
CHAMPVA | Benefit program for the spouse and dependent children of veterans with service connected disabilities or of veterans who died as a result of service connected disabilities |
Co-insurance | Policy holder and insurance company share the cost of covered benefits (e.g. 80/20) |
Commercial insurance plans | Also called Private Insurance- reimbursement is based on the policy |
Co-payment | Sum of money paid at the time of medical service |
Deductible | Fixed dollar amount that must be paid, "met" once a benefit year, before the insurance company begins to cover medical expenses |
Dependent | A person covered under the primary insured's policy |
Effective date | Date on which an insurance policy takes effect |
Exclusions | Limitations on an insurance contract for which benefits are not payable |
Explanation of Benefits | A claim summary indicating what services were covered, not covered and why, contains information on deductibles, co pays and allowed amounts |
Guarantor | Person responsible for paying a medical bill |
Participating provider | Physician who entered into a written contract with a specific insurance carrier and accepts their payment as payment in full and abides by their rules |
Referral | Authorization for an HMO patient to be seen by a physician other than their PCP |
TPA- Third Party Administrator | Organization that processes health claims for a health plan |
TRICARE | Government sponsored program under which dependents of active duty military personnel, retirees, and family members receive medical care |
Workers Compensation | Medical and disability insurance to cover employees in the event of a work related injury |