Chapter 15- Medical Insurance Billing Flashcards
Coinsurance
Fixed percentages of the cost of a service paid by the patient or a second insurance.
Premium
The payment for a health insurance policy.
CMS- 1500
A uniform billing form used for medical claims.
Clean Claim
Complete correct claim, with NO errors.
Gate Keeper
The primary provider who arranges specialists or hospitalizations.
Primary Policy
The medical insurance policy that is billed first.
Fee Schedule
A providers list of changes for services provided.
Medical Necessity
The process of establishing the need for a service.
Allowed Amount
The amount the insurance company determines to be a customary price for a service. Usually less then what the providee charges.
Elective Procedures
Commonly requires pre-Approval from the insurance company.
CPT
Identifies a procedure on a claim form. (5 digit #)
Dependents
Family members of the insured
Coordination of Benefits
Determining which Insurance is primary when the patient has more than one medical Insurance policy.
Beneficiaries
The individual who qualifies for the program.
Third Party Payer
Party other than the patient, who assumes responsibility to pay for the patients bill.
Participating Provider
One who has a contractual agreement with an insurance PLAN to lender care to eligible beneficiaries and then bill the insurance carrier directly.
Eligibility
Process of determining whether a patient is qualified to receive coverage OR paid benefits according to the insurance policy guidelines.
NPI
National
Provider
Identifier
CMS
Center of
Medicaid/Medicare
Services
MCO
Managed Care Organization
HMO
Health Maintenance Organization
DRG
Diagnosis Related Group
MG
MediGap
ABN
Advance Beneficiary Notice
