Ch 20 Flashcards
allowed charge (allowable amount)
maximum amount of money- many third party payers allow for specific procedure or service
authorization
alphanumeric/number given by the insurance company authorizing approval of a procedure or service (doesn’t guarantee payment)
beneficiary
person who receives benefits from insurance policy/program/government entitlement program (participant, subscriber, dependent, enrollee, member)
benefits
amount payable by insurance company for monetary loss to individual insured by the company, under each coverage
birthday rule
when an someone is covered by 2 policies, plan of the policyholder whose birthday comes first in the calendar year (month and day, not year) becomes primary insurance
capitation
used by many managed care organizations- fixed amount of money is reimbursed to the provider for patients enrolled during a specific period of time, no matter what services were received or how many visits were made
carriers
companies that assume the risk of an insurance policy
civilian health and medical program of the uniformed services (CHAMPUS)
see TRICARE
civilian health and medical program of the department of veterans affairs (CHAMPVA)
healthcare program in which the VA pays the covered services and supplies for eligible beneficiaries- the individual cannot be eligible for TRICARE, but can be the spouse or child of a disabled veteran, as well as the surviving spouse or child of a veteran who died from a service connected disability; a veteran who died while suffering a service disability; or a military member who died in the line of duty
co-insurance
policyholder and insurance company share the cost of covered losses in a specific ratio
commercial insurance plans
reimburse the insured for expenses resulting from illness or injury according to a specific fee schedule as outlined in the policy and on a fee-for-service basis (private insurance)
co-payment
a sum of money that is paid at the time of medical service; a form of co-insurance
deductibles
specific amounts of money a patient must pay out of pocket before the insurance carrier begins paying (ranges from $100 to $500) amount is met on a yearly or per-incident basis
dependents
spouse, children, and sometimes domestic partner or other individuals designated by the insured who are covered under a healthcare plan
disability income insurance
provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury or disease
effective date
when an insurance policy or plan takes effect so that benefits are payable
eligibility
whether a patient’s insurance coverage is in effect and eligible for payment of insurance benefits
exclusions
limitations on an insurance contract of which benefits are not payable
explanation of benefits (EOB)
letter or statement from insurance explaining what was paid, denied or reduced in payment; it also contains information about amounts applied to the deductible, pts co-insurance, and the allowed amounts
explanation of Medicare benefits (EOMB)
explanation of benefits from Medicare (see EOB)
fee for service
established schedule of fees set for services performed by providers and paid by the patient
fiscal intermediary
organization that contracts with gov to handle and mediate insurance claims from medical facilities, home health agencies, or providers of medical services or supplies
government plans
entitlement programs or healthcare plans that are sponsored and/or subsidized by the state or federal government, such as Medicaid or Medicare
grandfathered
legislative provision that allows the exception based on a preexisting condition
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
guarantor
the person responsible for paying a medical bill
health insurance
insurance protection, provided in return for periodic premium payments, provides reimbursement of expenses (from illness or injury)
health maintenance organization (HMO)
provides a wide range of comprehensive healthcare services for a specified group at a fixed periodic payment; can be sponsored by government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies, and hospital-medical plans
indemity 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; policyholders of indemnity plans and their dependents choose when and where to get healthcare services
individual policy
designed specifically for the use of one person and their dependents; generally does not offer some of the amenities of a group policy - (personal insurance)
insured
covered by an insurance policy according to the policy terms; usually the individual or group pays the premiums
managed care plans
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
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
medicaid
a federal and state sponsored health care insurance program for the medically indigent
medicare
a federally sponsored health insurance program for those over age 65 and for individuals under age 65 who are disabled
medigap
a term sometimes applied to private insurance products that supplement medicare insurance benefits
participating provider (PAR)
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
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
preauthorization
the provider obtains permission to perform certain procedures or services or refer a patient to a specialist
premium
period (monthly, quarterly, annual) payment to an insurance company, for which the insurer in return agrees to provide certain benefits
remittance advice (RA)
an explanation of benefits from medicaid (see EOB)
resource based relative value scale (RBRVS)
fee schedule designed to provide national uniform payment of medicare benefits after adjustment to reflect the differences in practice costs across geographic areas
rider
special provision or group of provisions that may be added to a policy to expand or limit the benefits otherwise payable; may increase or decrease benefits, waive a condition or coverage, or in any other way amend the original contract
self insured (self funded) plan
funded by an organization having a large enough employee base that it can afford to fund its own insruance program
self-referral
when a patient or an insured individual refers themselves to a specialist without requesting the referral from the primary provider
service benefit plans
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
third party administration (TPA
processes claims and performs other business related functions for a health plan
third party payers
entities that make payment on an obligation or debt but are not parties to the contract that created the debt
TRICARE
government sponsored program under which authorized dependents of military personnel receive medical care; originally called CHAMPUS
utilization review
review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources
workers’ compenstaion
system of laws that protects employees against the loss of wages and the cost of medical care resulting from an occupational accident, disease, or death unless the employee is proven negligent
