Ch 20

Question 1

allowed charge (allowable amount)

Answer 1

maximum amount of money- many third party payers allow for specific procedure or service

Question 2

authorization

Answer 2

alphanumeric/number given by the insurance company authorizing approval of a procedure or service (doesn’t guarantee payment)

Question 3

beneficiary

Answer 3

person who receives benefits from insurance policy/program/government entitlement program (participant, subscriber, dependent, enrollee, member)

Question 4

benefits

Answer 4

amount payable by insurance company for monetary loss to individual insured by the company, under each coverage

Question 5

birthday rule

Answer 5

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

Question 6

capitation

Answer 6

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

Question 7

carriers

Answer 7

companies that assume the risk of an insurance policy

Question 8

civilian health and medical program of the uniformed services (CHAMPUS)

Answer 8

see TRICARE

Question 9

civilian health and medical program of the department of veterans affairs (CHAMPVA)

Answer 9

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

Question 10

co-insurance

Answer 10

policyholder and insurance company share the cost of covered losses in a specific ratio

Question 11

commercial insurance plans

Answer 11

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)

Question 12

co-payment

Answer 12

a sum of money that is paid at the time of medical service; a form of co-insurance

Question 13

deductibles

Answer 13

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

Question 14

dependents

Answer 14

spouse, children, and sometimes domestic partner or other individuals designated by the insured who are covered under a healthcare plan

Question 15

disability income insurance

Answer 15

provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury or disease

Question 16

effective date

Answer 16

when an insurance policy or plan takes effect so that benefits are payable

Question 17

eligibility

Answer 17

whether a patient’s insurance coverage is in effect and eligible for payment of insurance benefits

Question 18

exclusions

Answer 18

limitations on an insurance contract of which benefits are not payable

Question 19

explanation of benefits (EOB)

Answer 19

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

Question 20

explanation of Medicare benefits (EOMB)

Answer 20

explanation of benefits from Medicare (see EOB)

Question 21

fee for service

Answer 21

established schedule of fees set for services performed by providers and paid by the patient

Question 22

fiscal intermediary

Answer 22

organization that contracts with gov to handle and mediate insurance claims from medical facilities, home health agencies, or providers of medical services or supplies

Question 23

government plans

Answer 23

entitlement programs or healthcare plans that are sponsored and/or subsidized by the state or federal government, such as Medicaid or Medicare

Question 24

grandfathered

Answer 24

legislative provision that allows the exception based on a preexisting condition

Question 25

group policy

Answer 25

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

Question 26

guarantor

Answer 26

the person responsible for paying a medical bill

Question 27

health insurance

Answer 27

insurance protection, provided in return for periodic premium payments, provides reimbursement of expenses (from illness or injury)

Question 28

health maintenance organization (HMO)

Answer 28

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

Question 29

indemity plans

Answer 29

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

Question 30

individual policy

Answer 30

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)

Question 31

insured

Answer 31

covered by an insurance policy according to the policy terms; usually the individual or group pays the premiums

Question 32

managed care plans

Answer 32

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

Question 33

medical savings accounts (MSAs)

Answer 33

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

Question 34

medicaid

Answer 34

a federal and state sponsored health care insurance program for the medically indigent

Question 35

medicare

Answer 35

a federally sponsored health insurance program for those over age 65 and for individuals under age 65 who are disabled

Question 36

medigap

Answer 36

a term sometimes applied to private insurance products that supplement medicare insurance benefits

Question 37

participating provider (PAR)

Answer 37

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

Question 38

policyholder

Answer 38

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

Question 39

preauthorization

Answer 39

the provider obtains permission to perform certain procedures or services or refer a patient to a specialist

Question 40

premium

Answer 40

period (monthly, quarterly, annual) payment to an insurance company, for which the insurer in return agrees to provide certain benefits

Question 41

remittance advice (RA)

Answer 41

an explanation of benefits from medicaid (see EOB)

Question 42

resource based relative value scale (RBRVS)

Answer 42

fee schedule designed to provide national uniform payment of medicare benefits after adjustment to reflect the differences in practice costs across geographic areas

Question 43

rider

Answer 43

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

Question 44

self insured (self funded) plan

Answer 44

funded by an organization having a large enough employee base that it can afford to fund its own insruance program

Question 45

self-referral

Answer 45

when a patient or an insured individual refers themselves to a specialist without requesting the referral from the primary provider

Question 46

service benefit plans

Answer 46

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

Question 47

third party administration (TPA

Answer 47

processes claims and performs other business related functions for a health plan

Question 48

third party payers

Answer 48

entities that make payment on an obligation or debt but are not parties to the contract that created the debt

Question 49

TRICARE

Answer 49

government sponsored program under which authorized dependents of military personnel receive medical care; originally called CHAMPUS

Question 50

utilization review

Answer 50

review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources

Question 51

workers’ compenstaion

Answer 51

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