KINNS Ch 20
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| allowed charge (allowable amount) | The maximum amount of money many third-party payers allow for a specific procedure or service.
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| authorization | A term used in managed care for an approved referral.
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| beneficiary | An individual entitled to receive benefits from an insurance policy or program or a government entitlement progra m offering healthcare benefits. Also called a participant, subscriber, dependent, enrollee, or member.
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| birthday rule | When an individual is covered by two insurance policies, the insurance plan of the policyholder whose birthday comes first in the calendar year (month and day, not year) becomes the primary insurance.
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| capitation | A payment method used by many managed care organizations in which a fixed amount of money is reimbursed to the provider for patients enrolled during a specific period of time, no matter what services are received or how many visits are made.
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| carrier | With regard to insurance, a company that assumes the risk of an insurance policy.
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| Civilian Health and Medical Program of the Veterans Administration (CHAMPVA) | A health benefits program run by the Department of Veterans Affairs (VA) that helps eligible beneficiaries pay the cost of specific healthcare services and supplies.
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| co-insurance | A policy provision frequently found in medical insurance whereby the policyholder and the insurance company share the cost of covered losses in a specified ratio. For example, 80/20 means 80% is covered by the insurer and 20% by the insured.
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| commercial insurance | Plans that reimburse the insured for expenses resulting from illness or injury according to a specific fee schedule as outlined in the insurance policy and on a fee-for-service basis; sometimes called private insurance.
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| co-payment | A sum of money paid at the time of medical service; a form of co-insurance.
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| deductible | A specific amount of money a patient must pay out of pocket before the insurance carrier begins paying, usually $100 to $500. The deductible amount is met on a yearly or per-incident basis.
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| dependent | The spouse, child, and sometimes domestic partner or others designated by the insured who are covered under a healthcare plan.
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| disability income insurance | Insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease.
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| effective date | The date on which an insurance policy or plan takes effect so that benefits are payable.
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| eligibility | A term that describes whether a patient's insurance coverage is in effect and eligible for payment of insurance benefits.
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| exclusions | Limitations on an insurance contract for which benefits are not payable.
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| explanation of benefits (EOB) | A letter or statement from the insurance carrier describing what was paid, denied, or reduced in payment. It also contains information about amounts applied to the deductible, the patient's co-insurance, and the allowed amounts.
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| explanation of Medicare benefits (EOMB) | An explanation of benefits from Medicare.
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| fee-for-service plans | Plans in which an established schedule of fees, which are paid by the patient, is set for services performed by providers.
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| fiscal intermediary | An organization that contracts with the government to handle and mediate insurance claims from medical facilities, home health agencies, or providers of medical services or supplies.
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| government plans | Entitlement programs or healthcare plans sponsored and/or subsidized by the state or federal government (e.g., Medicaid and Medicare).
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| group policy | Insurance written under a policy that covers a number of people under a single master contract issued to their employer or to an association with which they are affiliated.
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| guarantor | The person responsible for paying a medical bill.
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| health insurance | Protection in return for periodic premium payments that provides reimbursement of expenses resulting from illness or injury.
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| Health Insurance Portability and Accountability Act (HIPAA) | It was designed to improve the portability and continuity of health insurance coverage
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| health maintenance organization (HMO) | An organization that provides a wide range of comprehensive healthcare services for a specified group for a fixed, periodic payment.
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| indemnity plans | Traditional health insurance plans that pay for all or a share of the cost of covered services, regardless of which physician, hospital, or other licensed healthcare provider is used.
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| individual policy | An insurance policy designed specifically for the use of one person (and his or her dependents); it does not offer the benefit of the lower premiums available through a group policy. Often called personal insurance.
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| insured | An individual or organization covered by an insurance policy according to the policy terms, usually the individual or group that pays the premiums. Blue Cross/Blue Shield refers to this person or group as the subscriber.
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| managed care plans | An umbrella term for all healthcare plans that provide healthcare in return for preset monthly payments and coordinated care through a defined network of primary care physicians and hospitals.
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| Medicaid | A federal- and state-sponsored health insurance program for the medically indigent.
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| medical savings accounts (MSAs) | Tax-deferred bank or savings accounts that are combined with a low-premium, high-deductible insurance policy; they are designed for individuals or families who choose to fund their own healthcare expenses and medical insurance.
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| Medicare | A federally sponsored health insurance program for those over age 65 or individuals under age 65 who are disabled.
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| Medigap | A term sometimes applied to private insurance products that supplement Medicare insurance benefits.
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| participating provider (PAR) | A physician or other healthcare provider who enters into a contract with a specific insurance company or program and by doing so agrees to abide by certain rules and regulations set forth by that particular third-party payer.
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| policyholder | A person who pays a premium to an insurance company and in whose name the policy is written in exchange for the insurance protection provided by a policy of insurance.
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| preauthorization | A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services or refers a patient to a specialist.
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| premium | The periodic (monthly, quarterly, or annual) payment of a specific sum of money to an insurance company, for which the insurer in return agrees to provide certain benefits.
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| primary care provider (PCP) | A general practice or nonspecialist provider or physician responsible for the care of a patient for some health maintenance organizations. Also called a gatekeeper.
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| referral | An insurance term used when a primary care provider wants to send a patient to a specialist. Typically, the provider must obtain authorization from the insurance carrier in advance to refer a patient.
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| remittance advice (RA) | An explanation of benefits that comes from Medicaid; see explanation of benefits.
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| resource-based relative value scale (RBRVS) | A fee schedule designed to provide national uniform payment of Medicare benefits after being adjusted to reflect the differences in practice costs across geographic areas.
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| rider | A special provision or group of provisions that may be added to a policy to expand or limit the benefits otherwise payable. It may increase or decrease benefits, waive a condition or coverage, or in any other way amend the original contract.
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| self-insured plan | An insurance plan funded by an organization having a large enough employee base that it can afford to fund its own insurance program.
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| self-referral | A patient or insured individual who refers himself or herself to a specialist without requesting the referral from the primary provider, such as a woman seeking an annual gynecologic examination.
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| service benefit plans | Plans that provide benefits in the form of certain surgical and medical services rendered rather than cash. A service benefit plan is not restricted to a fee schedule.
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| third-party administrator (TPA) | An organization that processes claims and performs other business-related functions for a health plan.
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| third-party payor | A person other than the patient, spouse, or parent who is responsible for paying all or part of the patient's medical costs.
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| TRICARE | A government-sponsored program wherein authorized dependents of military personnel receive medical care. Formerly called the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).
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| utilization review | A review of individual cases by a committee to make sure services are medically necessary and to study how providers use medical care resources.
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| workers’ compensation | Insurance against liability imposed on certain employers to pay benefits and furnish care to injured employees and to pay benefits to dependents of employees killed in the course of or because of circumstances arising from their employment.
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