Chapter 18/ch 16 Review of Insurances
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| ajudicate | Determination for monetary settlement or payment
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| third-party payer | Insurance carrier is it intervenes to be hospital or medical expenses on behalf of beneficiaries for recipients
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| indemity | Benefits paid in a predetermined amount in the event of a covered loss
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| deductible | Amount the insured must pay in a calendar of the school year before insurance company begins the payment of benefits
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| carrier | Organization that offers protection against losses in exchange for premium
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| adjuster | Employee of the Worker's Compensation insurance carrier with the case is assigned a new follows the case until it is settled
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| premium | Periodic payment made to keep an insurance policy in force
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| eliminations period | . Of time after the beginning of a disability for which no benefits are payable
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| fiscal intermediary | Contractor that processes payments to providers on behalf of state or federal agencies or insurance companies
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| partial disability | Illness or injury preventing the insured from performing one or more functions of his or her occupation
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| total disability | Illness or injury prevent a person from performing his or her job, or any other work
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| permanent disability | Illness or injury temporarily not allowing a person to do their job
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| The four main stages of the lifecycle of an insurance claim | Submission, processing, adjudication, payment
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| What types of commercial health insurance plans | MCP, self-pay, indemity
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| HDHP | abbreviation for insurance plan w high deductible
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| true or false...Medicaid coverage benefits are the same across all states | FALSE
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| true or false..each state operates its own Medicaid program | True
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| Three Types of Tricare | Standard, Extra, Prime
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| Medigap insurance policies are oofered by ____________ and controlled by the ______________ | MCP, Government
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| Stark Regulation 1&2 | a doc cannot refer/send a pt to another doc/facility associated w that doc who is their family
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| CHAMPVA is a military service benefit program for | Retired and honor ably discharged no premium
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| an attachment to a policy excluding certain illnesses or disabilities is called | waivers
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| birthday plan | The rule most states use when a child is covered by both parent's health insurance determine primary
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| Elimination period is also known as the | Waiting period, expected
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| CMS-1500 form | I may only be optically scan from the original copy, uses red ink
HIAA
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| Claim scrubber | A service that receives insurance claims Addison sort them and electronically transmit them to ins companies
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| The standard unique help identify her that all healthcare providers use when submitting claims is called the | NPI
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| Pre-authorization is for | Medications, referrals, records,surgery
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| Pre-certification is for | Procedures
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| Predetermination determines | Money.. How much a service will be paid for
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| RBRVS | Medicare
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| FECA | Federal employee compensation act
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| Document that arrives from the Ins. company with insurance claim | EOB, if Medicare its RA
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| Reasonable fee | Usual, customary, justifiable
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| Usual fee | Amount for a certain demographic
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| Group model | HMO- individual
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| Staff model | HMO- physician hires, pays salary
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| Network model | HMO- plan with two or more practices
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| HSA FSA | Tax deferred contribution
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| Total and partial | Off job disability
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| Contractor processes payments to physicians on the half of state , federal | MCO
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| The time limit for submission of a Medicare claim | One fiscal year
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| Patient qualifies for Medicare and Medicaid is referred to as a | Medi medi
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| And attachment to a policy excluding certain illnesses or disabilities is called a | Waiver
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| The insured is also known as a | Policyholder recipient member subscriber
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| Under Workmen's Comp. two terms for permanent disability | Permanent and stationary, residual
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| AHIP government plan | Americas health insurance plans
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| A referral where the doctor direct directly tells the patient | Direct
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| A referral that is in writing and a letter or email | Formal
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| A referral when the doctor calls | Verbal
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| A referral where The patient calls the PCP | Self
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| Oldest of pre-paid plans as a gatekeeper and yearly c apitation usually no out of network benefits | HMO
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| Freedom of choice you know gate fee for out of network benefits usually needs pre-Certs and pre-auth | PPO
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| Like an HMO only there is a monthly capitation as opposed to yearly | IPA
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| IPA and HMO pays for ambulatory service PPO pay for hospital service | PPG
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| Combination plan HMO and PPO | POS
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| Partial and total disability by the state | SDI
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| Temporary and permanent disability when your hurt at work | Workers compensation
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| Participating Medicare is | Contracted
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| Non participanting Medicare is | Not contracted
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| Limit charge Medicare is | Not contracted, urgent care
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| "A"Medicare covers | Hospital
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| "B" Medicare covers | Ambulatory/office visits
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| "C" Medicare covers | Advantage plan A and B dental and vision
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| "D" Medicare covers | Medicine
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| Always secondary insurance and sponsored by state local federal governments, for poor and disabled | Medicaid
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| 60% insurance pays, 40% pt pays | Bronze
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| 80% insurance pays, 20% pt pays | Gold (higher premium, lower out of pocket)
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| 70% insurance pays, 30% pt pays | Silver (fair plan)
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| 65 and older,ABCD ins, bronze silver gold plan | Medicare
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| The term third-party pairs indicates the following are involved in healthcare reimbursement | Patient provider and payer
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| State insurance exchanges | I called market places, offer insurance based on gender age and location, or offered in every state and maybe used by all noncitizens residing in the US
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| The parent whose birthday falls earlier in the calendar year by month will pay for in a health care plan is part of the | Birthday rule
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| State disability is available in | California Hawaii New Jersey New York and Rhode Island
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| Get a workers comp case the medical assistant communicates with | Adjuster
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| The CMS 1500 claim form has an assignment of benefits for government programs in | Field 12
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| CMS-1500 is in red to | Comply w OCR machines
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| When comparing electronic versus paper claim submission the average processing time is | 28 to 30 days for paper and 7 to 10 days for electronic
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