Health Insurance Terminology Commercial (MA Fall 2014)
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
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| Allowable | Maximum amount of money that many third-party payers allow for a specific procedure/service
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| Actual charge | Charge the physician submits for his services to the insurance carrier
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| Authorization | Number given by the insurance company authorizing approval of a procedure/service. Does not guarantee payment
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| Beneficiary | Person entitled to receive benefits from an insurance policy
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| 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
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| Capitation | Payment used by managed care plans; fixed payment is reimbursed to the provider for patients enrolled under his/her name
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| Carrier | Insurance companies that provide the policy and benefits
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| 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
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| Co-insurance | Policy holder and insurance company share the cost of covered benefits (e.g. 80/20)
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| Commercial insurance plans | Also called Private Insurance- reimbursement is based on the policy
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| Co-payment | Sum of money paid at the time of medical service
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| Deductible | Fixed dollar amount that must be paid, "met" once a benefit year, before the insurance company begins to cover medical expenses
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| Dependent | A person covered under the primary insured's policy
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| Effective date | Date on which an insurance policy takes effect
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| Exclusions | Limitations on an insurance contract for which benefits are not payable
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| Explanation of Benefits | A claim summary indicating what services were covered, not covered and why, contains information on deductibles, co pays and allowed amounts
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| Guarantor | Person responsible for paying a medical bill
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| 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
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| Referral | Authorization for an HMO patient to be seen by a physician other than their PCP
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| TPA- Third Party Administrator | Organization that processes health claims for a health plan
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| TRICARE | Government sponsored program under which dependents of active duty military personnel, retirees, and family members receive medical care
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| Workers Compensation | Medical and disability insurance to cover employees in the event of a work related injury
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