chapters 15 and 16
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Anaphylaxis | sever allegic reaction
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| CPR mouth barrier | disposable barrier device used to prevent infection
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| crash cart | wheeled cart that contains emergency medical equipment
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| defibrilator | device that delivers an electric shock to a patient
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| syncope | fainting; the sudden loss of consciousness
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| AAMA | American Association of Medical Assistants
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| ABCD | airway, breathing, circulation, defibrilation
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| AED | automatic external defibrillator
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| AHA | American Heart Association
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| CPR | cardiopulmonary resuscitation
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| FEMA | Federal Emergency Management Agency
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| HEPA | high efficiency particulate air filter
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| OSHA | Occupational Safety and Health Administration
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| PPE | personal protective equipment
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| abstract | te process of locating data in multiple source documents and accurately transferring it to a form
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| accept assignment | physician agrees to accept the amount approved by the insurance company as payment in full for a given service
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| advance beneficiary notice | a form patients sign agreeing to pay for covered Medicare services that may be dened due to medical necessity or frequency
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| allowed amount | the dollar amount for a service that an insurance company considers acceptable and uses to determine benefit payments AKA: approved amount
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| ancillary coverage | insurance coverage for services provided by other than a physician or hospital, such as dental, vision, or chiropractic care
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| appeal | process of asking for a review of a denied service or claim
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| approved amount | see allowed amount
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| assignment of benefits | request made by a patient to allow the insurance carrier to pay the health cre professional directly rather than issuing monies to the patient
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| balance billing | billing a patient for the dollar difference between the provider's charge and the insured approved amount; usually not permitted for participating providers
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| beneficiary | person who is elegible to receive benefits/services under an insurance policy
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| birthday rule | the parent with the birthday earlier in the year is the primary carrier for the children; the parent with the later birthday is the secondary carrier
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| bundling | combining multiple services under a single all inclusive CPT code and one charge
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| capitation plans | health care plans in which providers are paid set fees per month per member patients
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| caretaker | person or entity responsible for determining when and if a patient needs specific types of halth care; also called a gatekeeper or primary care provider (PCP)
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| carve outs | services that are reimbursed in addition to the base rate for the patient
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| catastrophic | large and usually unforeseen
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| categorically needed | Medicaid eligible patients who qualify for cash assistance as well as medical services
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| certificate of coverage | a letter from the insurance company that provides proof of type and timeframe of coverage when a patient teminates a health insurance policy
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| charge slip | document on which the physician indicates procedure and diagnosis codes; also called a routing slip; or see an encounter form
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| clean claim | insurance claim with no data errors
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| coinsurance | percentage of medical charges patients are responsible for according to their insurance plan contracts
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| commercial insurance | see private insurance
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| consumer-directed health care plans | health insurance plana that place patients in charge of how hteir health care dollars are spent
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| conversion factor | a constant dollar value multiplied by the relative value unit to determine the price of individual services
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| coordination of benefits | the process of determining which insurance policy should be billed first, second, or third when a patient is covered by multiple policies
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| copayment | set dollar fee per visit or service that patients are responsible for according to their insurance plan contracts
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| covered | services potentially eligible for reimbursement
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| deductable | monetary amount patients must pay to the provider for health care services before their health insurance benefits begin to pay
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| denied | a claim processed by an insurer and determined not eligible for payment
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| dependent | a family member or other individual who qualifies for coverage on the insured's policy; also called beneficiary, SEE ALSO insured;policy holder
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| disability insurance | insurance that covers other benefits due to a disability that prevents the individual from working
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| e-billing | process of sending health insurance claims electronically
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| elective procedure | procedure that will benefit the patient but does not need to be scheduled immediately
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| encounter form | document in which te physician indicates procedure ad diagnosis codes; also called a routing slip or charge slip
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| end-stage renal disease | total or nearly complete failure of the kidneys
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| exclusions | procedures or services not covered under an insurance plan
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| exclusive provider organization | a managed care contract with a smaller network of providers under which the employer agrees not to use any other networks in return for favorable pricing
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| explanation of benefits | a statement that accompanies payment from the insurance company which summarizes how the payment for each billed service was calculated and gives reasons for any items not paid
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| fee-for service | process in which insurance companies pay providers fees for each service provided to covered patients
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| fee schedule | list of the approved fees insurance carriers agree to pay to participating providers wh agree to contract with the carriers; also refers to the standard set of fees the provider chares to all insurers
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| flexible spending account | account into which employees place pretax earnings for projected medical expenses; also called health care reimbursement account
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| form locators | the boes to be completed on the CMS-1500 claim form
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| formulary | tiered list of drugs covered by an insurance company
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| gatekeeper | see caretaker
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| generic drugs | low-cost medications that duplicate their name brand counterparts in active ingredients and effect
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| geographical adjustment factor (GAF) | a numeric multiplier used by Medicare to adjust fees for the varying costs of practicing medicine in different areas of the country
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| group health insurance | a commercial insurance policy with rates based on a group of people, usually offered by an employer
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| health care reimbursement account | see flexible spending account
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| health maintenance organization | a group of physicians or medical centers that provides comprehensive service to members under a capitated payment plan; members care is covered only when using the designated providers
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| health savings account | tax free savings account used for medical expenses in conjunction with a high deductable health plan
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| hospice | facility or service for patients who are diagnosed with terminal illness and are expected to have 6 or fewer months to live
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| hospital services | patient care provided by a licensed acute care hospital
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| indemnity | see fee for service
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| individual insurance | a commercial insurance policy with rates based on individual health criteria
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| individual practice association | HMO'S tht are the most decentralized and involve contracting with individual physicians to create a healthcare delivery system
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| inpatient | a person who is admitted to the hospital for a minimum of 24 hours
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| insured | person who holds or owns an insurance policy; same as the member or the policyholder
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| liability insurance | type of insurance that covers injuries that occur on, in, or because if the insured's property
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| lifetime maximum benefit | monetary amount aloowed by an insurance carrier for a covered member's covered expenses over the member's lifetime
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| limiting charge | the maximum amount a Medicare non-PAR provider may bill the patient on an unassigned claim; 115% of the non-PAR fee schedule
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| long term disability insurance | insurance that covers lost wages and certain other benefits due to a disability that prevents the individual from working, usually for more than one year
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| managed care | a system of healthcare delivery focused on reducing costs by transferring risk to the provider and may limit the type and frequency of care members may receive
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| Medicaid | a joint federal and state program that helps with medical costs for some people with low incomes and limited resources
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| medical nessecity | criteria establishing when a service is appropriate
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| medical savings account | tax-free savings account for small employers and self-employed; used for medical expenses in conjunction with a high-deductable health plan
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| medically needy | Medicaid-eligible patients who are eligible for medical services, but not cash assistance
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| Medicare | federal program that covers medical expenses for those aged 65 and over, those with end-stage renal disease, and those with long term disabilities
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| member | the person who owns the insurance policy
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| negotiated fee schedule | a common reimbursement method in managed care whereby the MCO develops a list of fees for providers that they agree to accept in the participationg provider contract.
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| non-covered | services not eligible for reimbursement under any circumstances
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| nonparticipating provider | health care provider who has not contracted with a particular health insurance carrier
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| outliers | exceptional circumstances that cost far more or less than average
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| outpatient | a person who receives medical care at a hospital or other medical facitlity but who is not admitted for more than 24 hours
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| participating provider | health care provider who has contracted with a particular health insurance carrier
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| past timely filing limits | tme beyond which an insurance carrier will accept an insurance claim
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| payor number | unique identifying number assigned to each insurance carrier for the purpose of directing electronic claims
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| per case | per case payment method is used for hospitals; under this method, the hospital receives a pre-established amount per patient for the entire stay, based on the patient's diagnosis, regardless of how long htey are in or what services were provided
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| per diem | PER DAY payment method whereby the facility is paid a flat amount per day the patient remains, regardless of what services are provided
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| physician services | patient care provided by a licensed physician
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| point of service | an insurance offering in which a patient has acces to multiple plans, such as HMO
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| policyholder | person who holds or owns an insurance policy; same as the member or the insured
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| preauthorization | approval for treatment or service obtained from an insurance company before the care is provided
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| precertification | see preauthorization
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| pre-existing condition | condition for which a patient received treatment in certain time period before beginning coverage with a new insurance plan
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| preferred provider organization | organization that contracts with independant providers to preform services for members at discounted rates
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| premium | dollar amount paid to the insurance company to have coverage in force; usually paid monthly; employers may pay part or all of the premium as an employee benefit
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| preventative care | health care designed to keep a person healthy
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| private insurance | insurance not provided by the government but by an independant not-for-profit or for-profit company; also called commercial insurance
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| rejected | a claim that is returned to the provider without processing due to a technical error
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| relative value unit | unit of measurment assigned to medical services based on the resources required to provide it, includes work, practice expense, and liability insurance
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| resource based relative value scale | the methodology Medicare uses to establish physician fees, based on the relative value unit, the geographical adjustment factor, and the conversion factor
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| respite care | temporary care provided by an outside party to relieve the usual caregiver
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| self-insurance | type of insurance where rather than purchasing a commercial insurance policy, an employe sets aside a large reserve fund to directly reinburse employees for medical expenses
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| skilled nursing facitlity | a licensed facitlity whih primarily provides inpatient, skilled nursing care to patients who require medical, nursing, or rehabilitative services but does not provide the level of are or treatment available in a hospital
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| sliding scale fee | a provider's fee schedule that charges varying fees for the service based on a patient's financial ability to pay
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| staff model HMO | employs salaried physicians who treat members in facilities owned an operated by HMO
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| stop loss | the max amount the patient must pay out-of-pocket for copyments and coinsurance
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| subscriber | person who holds or owns an insurance policy; same as the member, or see the insured
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| superbill | document on which the physician indicates procedure and diagnosis codes; also called a routing slip or an encounter form
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| third-party administrator | a company that processes paperwork for claims for a self-insured employer
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| TRICARE | health insurance administered by the U.S. Dept of Defense for active duty military personnel, retired service personnel, and their eligible dependents; formally known as Civilian Health and Medical Program (CHAMPUS)
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| unbundling | billing multiple services with seperate CPT codes and sperate charges that should be combined under a single CPT code and one charge
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| usual, customary, and resonable (UCR) fee | a fee determined by third party payers to reimburse providers based on the provider's normal fee, the range of fees charges by provider's of the same specialty in the same geographical area, and other factors to determine app. fees in unusual situations
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| waiting period | period after a new health insurance plan begins during which certain services are not covered
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| waiver | see advance beneficiary notice
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| worker's compensation | insurance coverage for job-related illness or injury provided by employers
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| ABN | advance beneficiary notice
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| ADA | American Dental Association
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| CDHP | Consumer Directed Health Plan
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| CF | conversion factor
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| CHAMPVA | Civilian Health ad Medical Program of the Veterans Administration
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| CMS | Centers for Medicare and Medicaid
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| COB | coordination of benefits
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| COBRA | Consolidated Omnibus Budget Reconciliation Act
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| CPT | Current Procedural Terminology
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| CSRS | civil service
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| DEERS | defense enrollment eligibility reporting system
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| DME | durable medical equipment
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| EMC | electronic media claims
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| EOB | explination of benefits
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| EPO | Exclusive provider organization
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| ESRD | end-stage renal disease
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| FERS | Federal employee retirement system
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| FL | form locator
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| FSA | flexible spending account
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| GAF | geographical adjustment factor
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| HCFA | Health Care Financing Administration
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| HCRA | health care reimbursement account
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| HIPAA | Health Insurance Portability and Accountability Act
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| HMO | health maintenance organization
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| HSA | Health Savings Account
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