HIT Chapter 4
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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| Balance billing | practice of billing patient for any balance left after deductibles, coinsurance, and insurance payments have been made.
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| Birthday rule | informal procedure used to help determine which health insurance plan is primary when individuals are listed as dependents on more than one health plan
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| Cafeteria plan | type of plan that deducts the cost of the plan from the employee’s wages before taxes for some insurance premiums, unreimbursed medical expenses, and child/dependent care expenses
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| CMS-1500 form | the standard or “universal” claim form used to bill for all government and some commercial payers for outpatient and physician services
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| Coinsurance | a type of cost sharing between the insurance provider and the policyholder where the patient and the insurance pay a specified percentage of the charges billed
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| Comprehensive plan | a type of policy that combines basic and major medical coverage into one plan
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| COBRA-Consolidated Omnibus Reconciliation Act | guarantees employees the right to temporarily continue their health benefits after quitting or being terminated from a job
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| COB-coordination of benefits | determines the total benefits that primary and secondary insurance is allowed to pay. Both companies payments can not exceed 100% of the allowable charges
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| Deductible | set amount that a patient must pay out of pocket before the insurance company will begin to pay
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| Disability insurance | a type of insurance that provides weekly or monthly payment for lost income resulting from accidents or sickness or both that are not work related
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| Exclusions | illnesses or injuries not covered by the health insurance policy
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| Group contract | a contract of insurance made with a company, corporation, or other groups of common interest wherein all employees or individuals are insured under a single policy. Everyone receives the same benefits.
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| Indemnity(fee for service) | the standard type of health insurance individuals can purchase, which provides comprehensive major medical benefits and allows insured individuals to choose any physician or hospital when seeking medical care
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| nonPAR-nonparticipating provider | provider that has no contractual agreement with the insurance carrier and does not have to accept the insurance companies’ reimbursement as payment in full
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| Out of pocket maximum | amount of medical expenses paid by the patient after which the UCR is paid in full by the insurer
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| PAR-participating provider | a provider who contracts with a payer and agrees to abide by certain rules and regulations of that carrier
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| Policyholder | the insured;individual whose name is on the policy
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| Preexisting condition | physical or mental condition that existed before the effective date of an insurance policy
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| Premium | specific amount of money paid by the insured to the insurance company in exchange for financial protection against loss
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