Chapter 13 Flashcards
Third party payer
Any payment for medical services that is not paid by the patient or physician is said to be paid
Which is frequently not covered in group health benefits packages
Birth control
What determines Eligibility
Usually requires that children be unmarried
Who do you contact to check eligibility of a patient for the health benefits plan
Claims administrator
- check back of patients card for web address or phone number to contact claims administrator
What info is needed to fill out a CMS-1500 claim form
Diagnostic codes from encounter form
Medicare part A
Covers hospital expenses and is provided at no additional charge to persons eligible for social security benefits
Medicare part B
Pays for physician fees, specific tests.
Optional and the participant is charged a monthly fee. Fee is deducted from social security benefits
Health care savings account
Employee benefit that allows individuals to save money through payroll deduction to accounts that can be used only for medical care
After the deductible has been met what percentage of the approved charges does Medicare reimburse to physician
80%
Medicaid provides 100% coverage for
- family planning
- inpatient hospital care
- outpatient treatment and services
- diagnostic services
- skilled nursing facilities
- diagnostic screenings for children
In a traditional insurance plan
The covered patient may seek care from any provider
Government health sponsored health benefits plan
Tricare/champva
Four key elements of managed care program
- precertification
- approved referrals
- network
- assignment of benefits
Gatekeeper
Primary care physician
Seeks to reduce the plan costs of specialists
Birthday rule
Plan of the parent whose birthday occurs first each calendar year is the primary plan
