Chapter 15- Medical Insurance Billing Flashcards

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1
Q

Coinsurance

A

Fixed percentages of the cost of a service paid by the patient or a second insurance.

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2
Q

Premium

A

The payment for a health insurance policy.

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3
Q

CMS- 1500

A

A uniform billing form used for medical claims.

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4
Q

Clean Claim

A

Complete correct claim, with NO errors.

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5
Q

Gate Keeper

A

The primary provider who arranges specialists or hospitalizations.

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6
Q

Primary Policy

A

The medical insurance policy that is billed first.

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7
Q

Fee Schedule

A

A providers list of changes for services provided.

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8
Q

Medical Necessity

A

The process of establishing the need for a service.

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9
Q

Allowed Amount

A

The amount the insurance company determines to be a customary price for a service. Usually less then what the providee charges.

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10
Q

Elective Procedures

A

Commonly requires pre-Approval from the insurance company.

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11
Q

CPT

A

Identifies a procedure on a claim form. (5 digit #)

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12
Q

Dependents

A

Family members of the insured

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13
Q

Coordination of Benefits

A

Determining which Insurance is primary when the patient has more than one medical Insurance policy.

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14
Q

Beneficiaries

A

The individual who qualifies for the program.

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15
Q

Third Party Payer

A

Party other than the patient, who assumes responsibility to pay for the patients bill.

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16
Q

Participating Provider

A

One who has a contractual agreement with an insurance PLAN to lender care to eligible beneficiaries and then bill the insurance carrier directly.

17
Q

Eligibility

A

Process of determining whether a patient is qualified to receive coverage OR paid benefits according to the insurance policy guidelines.

18
Q

NPI

A

National
Provider
Identifier

19
Q

CMS

A

Center of
Medicaid/Medicare
Services

20
Q

MCO

A

Managed Care Organization

21
Q

HMO

A

Health Maintenance Organization

22
Q

DRG

A

Diagnosis Related Group

23
Q

MG

A

MediGap

24
Q

ABN

A

Advance Beneficiary Notice

25
Q

COB

A

Coordinations of Benefits

26
Q

PCP

A

Primary Care Provider

27
Q

FFS

A

Fee For Service