Chapter 4

Question 1

Benefits

Answer 1

the amount of money a health plan pays for services covered in an insurance policy

Question 2

capitation

Answer 2

a prepayment covering providers services for a plan members a specified period

Question 3

coinsurance

Answer 3

The portion of charged that an insured person must pay for health care services after payment of the deductible

Question 4

copayment (copay)

Answer 4

an amount tat health plans requires beneficiary to pay at the time of services for each health care encounter

Question 5

Covered services

Answer 5

medical procedures and treatments that are included as benefits under an insured’s heath plan

Question 6

Deductible

Answer 6

an amount that an insured person must pay usually on an annual basis for health care services before an health plans payments begins

Question 7

established patient (EP)

Answer 7

patient who has received professional services from a provider with in the past three years

Question 8

fee-for-service

Answer 8

health plan that repays the policyholders for covered medical expenses

Question 9

Health plan

Answer 9

An individual or group plan that either provides or pays for the cost of medical care: includes group health cares.

Question 10

indemnity plan

Answer 10

type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits

Question 11

Managed care

Answer 11

system that combines the financing and delivery of appropriates, cost-effective health care services to its memebers

Question 12

medical insurance

Answer 12

financial plans that covers the cost of hospital and medical care

Question 13

new patient (NP)

Answer 13

a patient who has not received professional services from a provider within the past three years

Question 14

non covered services

Answer 14

medical procedures that are not included in a plans benefits

Question 15

nonparticipating (non PAR) provider

Answer 15

a provider who chooses not to join a particular government or other health plans

Question 16

office hours calendar

Answer 16

an interactive calendar that is used to select or change dates in office hours

Question 17

office hours patient information

Answer 17

the area of the office hours window that displays information about the patient who is selected in the providers daily schedule

Question 18

out-of-network

Answer 18

provider that dose not have a participation agreement wit h a plan using an out-of-network provider is more expensive for the plans enrollees

Question 19

out-of- pocket

Answer 19

expenses the insured must pay before benefits begin

Question 20

participating (PAR) provider

Answer 20

provider who agrees to provide medical services to a payer’s policyholders according to the terms of the plans of contracts

Question 21

patient portal

Answer 21

secure website that enables communication between patients and health care providers for tasks such as scheduling, completing registration forms and making payments

Question 22

payer

Answer 22

Health plan or program

Question 23

policyholder

Answer 23

person who buys an insurance plan that insured subscriber or guarantor

Question 24

preexisting condition

Answer 24

illness or disorder of a beneficiary that existed before the effective date of insurance coverage

Question 25

premium

Answer 25

Money the insured pays to a health plan for a health care policy; usually paid monthly

Question 26

preregistration

Answer 26

the process of gathering basic contact, insurance, and reason for visit information before a new patient comes into office for an encounter

Question 27

preventive medical services

Answer 27

care that is provided to keep patients healthy and to to prevent illness such as check ups and screening

Question 28

provider

Answer 28

person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business

Question 29

providers daily schedule

Answer 29

listing of time slots for a particular day for a specific provider that corresponds to the date selected in the calender

Question 30

provider selection box

Answer 30

selections box that determine which provider schedules is displayed in the providers daily schedule

Question 31

referral

Answer 31

transfer of patient care from one physician to another

Question 32

referral number

Answer 32

authorization number given by a referring physician to the referred physician

Question 33

schedule of benefits

Answer 33

list of the medical expenses that a health plan covers

Question 34

preauthorization

Answer 34

prior authorization form a payer for services to be provided