Medical Terminology
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| Health insurance is a contract between | a policy holder and an insurance carrier
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| group insurance | a group of employees and their dependents are insured under 1 group policy issued to the employer
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| personal insurance | an insurance plan issued to an individual
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| pre-paid health plan | pre-determined set of benefits covered under one set annual fee
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| health maintenance organization (HMO) | a managed care benefits plan that provides a wide range of medical services to idividuals enrolled - must have a primary care physician
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| preferred provider organization (PPO) | like a HMO, but more flexiable - pay higher premiums - no primary care physician
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| point-of-service plan (POS) | managed care plan that gives beneficiaries the option whom to see for services.
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| Medicare Part A | covers hospital and hospice care
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| Medicare Part B | covers medical expenses for Dr visits and lab tests
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| Medicare Part D | covers prescription drugs
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| advance beneficiary notice | a document provided to a medicare beneficiary by a provider prior to service being rendered letting the beneficiary know of their responbility to pay if medicare denies the claim
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| medigap (medicare supplemental insurance) | this covers medical services that medicare denies (coinsurance)
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| blue cross | covers hospital services
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| blue shield | covers physician services
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| assignment of benefits | reimbursement is directly sent from payer to the provider
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| accept assignment | the provider agrees to accept what the insurance company approves as payment in full
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| fee-for-service | a fee that is charged for each procedure or service performed by the physician
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| fiscal intermediary | an insurance company that bids for a contract with CMS to handle the Medicare program in a specific area
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| premium | the cost of insurance coverage
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| deductible | out of pocket amount that must be paid annually
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| coinsurance | percentage of cost of the covered services that a policyholder or a secondary insurance pays
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| co-payment | a cost sharing requirement for the insured to pay at the time of service
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| coding | the process of converting diagnoses, procedures and services into numeric and alphanumeric characters
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| exclusions and limitations | conditions, situations and services NOT covered by the insurance
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| pre-certification | to determine the patient's benefits and the maximum dollar amount that the insurance company will pay
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| pre-authorization | a requirement for some health insurance plans to obtain permission for a service or procedure before it is done
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| qualified diagnosis | a working diagnosis which is not yet established
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| eligibility | the qualifying factor or factors that must be met before a patient receives benefits
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| coordination of benefits (COB) | when 2 insurance companies work together to coordinate payment of the benefits
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| peer review organization (PRO) | a state based group of physicians working under government guideline to review cases and determine their appropriateness and quality of professional care
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| civil monetary penalties law (CMPL) | law passed by the federal government to prosecute cases of medicaid fraud
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| remittance advice | an electronic or paper-based report of payment by the payer to the provider
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| patient's bill of rights | developed to promote the interests and well being of the patients and residents of the health care facility
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