Chapter 7 Definitions

Question 1

medical insurance

Answer 1

a contract between a policyholder and an insurance company to reimburse a percentage of the cost of the policyholder’s medical bills

Question 2

policy

Answer 2

a contract between an insurance company and an individual or organization

Question 3

health insurance

Answer 3

a type of policy designed to reimburse the cost of preventative as well as corrective medical care

Question 4

athletic accident insurance

Answer 4

a type of insurance policy intended to reimburse medical cendors for hte expenses assoicated with acute athletic accidents

Question 5

exclusions

Answer 5

situations or circumstances specifically not covered by an insurance policy

Question 6

rider

Answer 6

additions to a standard insurance policy that provide coverage for conditions that are normally not covered

Question 7

premium

Answer 7

the invoiced cost of an insurance policy

Question 8

catastrophic insurance

Answer 8

a type of accident insurance designed to provide lifelong medical, rehabilitation, and disability benefits for the victims of devastating injury

Question 9

disability insurance

Answer 9

insurance designed to protect an athlete agaiinst future loss of earnings because of a disabling injury or sickness

Question 10

experimental treatments

Answer 10

therapies not proved effective

Question 11

usual, customary, and reasonable fee (URC)

Answer 11

the charge consistent with what other medical vendors would assess

Question 12

90th-percentile fee

Answer 12

the fee below which 90% of all other medical vendors in a particular geographic area charge for a speific service

Question 13

primary coverage

Answer 13

a type of health, medical, or accident insurance that begins to pay for covered expenses immediately after a deductible has been pain

Question 14

secondary coverage

Answer 14

a type of health, medical, or accident insurance that begins to pay for coverage expenses only after all other sources of insurance coverage have been exhausted. also known as excess insurance

Question 15

third-party reimbursement

Answer 15

the process by which medical vendors receive reimbursement form insurance companies for services provided to policyholders

Question 16

third-party

Answer 16

a medical vendor with no binding interest in a particular insurance contract

Question 17

fee-for-service plan

Answer 17

also known as an indemnity plan. a type of traditional medical insurance wherby patients are free to seek medical services from any provider. The plan covers a portion of the cost of covered procedures, and the patient is responsible for the balance

Question 18

health maintenance organization (HMO)

Answer 18

a type of health insurance plan that requires policyholders to use only those medical vendors approved by the compnay. all medical services are coordinated by a primary care physician, who acts as a gatekeeper to specialty services

Question 19

capitation

Answer 19

a system wherby medical vendors receive a fixed amount per patient

Question 20

individual practice association (IPA)

Answer 20

a managed-care model whereby a HMO provides helath care services through a network of individual medicla practitioners. care is provided in a physician’s office as opposed to a large, multifuntional medical center

Question 21

preferred provider organization (PPO)

Answer 21

a type of health insurance plan that provides financial incentives to encourage policyholders to use medical vendors approved by the company

Question 22

exclusive provider organizaiton (EPO)

Answer 22

a type of PPO wherby medical services are reimbursed only if the patient uses contracted providers

Question 23

point-of-service plan (POS)

Answer 23

managed-care plans that are similar to PPOs, except that primary care physicians are assigned to patients to coordinate their care

Question 24

fraud

Answer 24

criminal misrepresentation for the purpose of financial gain

Question 25

international classification of diseases (ICD-9-CM)

Answer 25

a coding system applied to illnesses, injuries, and other medical conditions to standardize the language associated with third-party reimbursement

Question 26

current procedural terminology (CPT)

Answer 26

a coding system applied to medical procedures to standardize the language associated with third-party reimbursement

Question 27

managed care

Answer 27

a growing concept in the insurance industry emphasizing cost control through coordination of medical services, such as with an HMO or PPO

Question 28

primary care provider

Answer 28

the physician, selected by an HMO member, who acts as the first source of medical service for the patient. most HMOs requrie members to seek a referral from the primary care provider before seekign care form another medical vendor

Question 29

CMS 1500

Answer 29

the form that private-practice clinics should use when filing a claim with an insurance company. orginally developed by the health care financing administration (now known as the centers for medicare and medicaid services) for Medicare claims

Question 30

UB-92 AKA CMS 1450

Answer 30

insurance claim form that hospitals should use

Question 31

electronic data interchange (EDI)

Answer 31

a system wherby insurance claims can be submitted electronically. also known as paperless claims system

Question 32

insurance agent

Answer 32

a repesentative of an insurance company or an independent insurance agency who sells and services insurance policies

Question 33

layered coverage

Answer 33

a method of using different insurance companies to underwrite different levels of coverage in a common policy

Question 34

copayments

Answer 34

the percentage of a medical bill not paid for by the insurance company