CMAA

Question 1

Allowed charge (allowable amount)

Answer 1

The maximum amount of money many third-party payers allow for a specific procedure or service

Question 2

Authorization

Answer 2

A term used in managed-care for an approved referral

Question 3

Beneficiary

Answer 3

An individual entitled to receive benefits from an insurance policy or program or government entitlement program offering healthcare benefits

Question 4

Birthday rule

Answer 4

When an individual is covered by two insurance policies the insurance plan of the policyholder whose birthday comes first in the calendar year (month and day not year) becomes the primary insurance

Question 5

Capitation

Answer 5

A payment method used by many managed care organizations in which a fixed amount of money is reimbursed to the provider for patients enrolled during a specific period of time, no matter what services are received or how many visits are made

Question 6

Carrier

Answer 6

With regard to insurance, a company that assumes the risk of an insurance policy

Question 7

Civilian Health and Medical Program of the Veterans Administration (CHAMPVA)

Answer 7

A health benefits program run by the Department of Veterans Affairs (VA) that helps eligible beneficiaries pay the cost of specific healthcare services and supples

Question 8

Co-insurance

Answer 8

A policy provision frequently found in medical insurance whereby the policyholder and the insurance company share the cost of covered losses in a specified ratio. For example, 80/20 means 80% is covered by the insurer and 20% by the insured

Question 9

Commercial insurance

Answer 9

Plans that reimburse the insured for expenses resulting from illness or injury according to a specific free schedule as outlined in the insurance policy and on a fee-for-service basis; sometimes called private insurance

Question 10

Co-payment

Answer 10

A sum of money paid at the time of medical service; a form of co-insurance

Question 11

Deductible

Answer 11

A specific amount of money a patient must pay out of pocket before the insurance carrier begins paying, usually $100 to $500. The deductible amount is met on a yearly or per-incident basis

Question 12

Dependent

Answer 12

The spouse, child, and sometimes domestic partner or others designated by the insured who are covered under a healthcare plan

Question 13

Disability income insurance

Answer 13

Insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease

Question 14

Effective date

Answer 14

The date on which an insurance policy or plan takes effect so that benefits are payable

Question 15

Eligibility

Answer 15

A term that describes whether a patient’s insurance coverage is in effect and eligible for payment of insurance benefits

Question 16

Exclusions

Answer 16

Limitations on an insurance contract for which benefits are not payable

Question 17

Explanation of benefits (EOB)

Answer 17

A letter or statement from the insurance carrier describing what was paid, denied, or reduced in payment. It also contains information about amounts applied to the deductible, the patient’s co-insurance, and the allowed amounts

Question 18

Explanation of Medicare benefits (EOMB)

Answer 18

An explanation of benefits from Medicare

Question 19

Fee-for-service plans

Answer 19

Plans in which an established schedule of fees, which are paid by the patient, is set for services performed by providers

Question 20

Fiscal intermediary

Answer 20

An organization that contracts with the government to handle and mediate insurance claims from medical facilities, home health agencies, or providers of medical services or suppplies

Question 21

Government plans

Answer 21

Entitlement programs or healthcare plans sponsored and/or subsidized by the state or federal government (e.g., Medicaid and Medicare

Question 22

Group policy

Answer 22

Insurance written under a policy that covers a number of people under a single master contract issued to their employer or to an association with which they are affiliated

Question 23

Guarantor

Answer 23

The person responsible for paying a medical bill

Question 24

Health insurance

Answer 24

Protection in return for periodic premium payments that provides reimbursement of expenses resulting from illness or injury. Types of health insurance available include accident, disability income, medical expense, and accidental death and dismemberment insurance. Also known as “accident and health insurance” or “disability income insurance”

Question 25

Health Insurance Portability and Accountability Act (HIPPA)

Answer 25

The Kassebaum-Kennedy Act, which was passed in 1996. It was designed to improve the portability and continuity of health insurance coverage; to combat waste, fraud, and abuse in health insurance and healthcare delivery; to promote the use of medical savings accounts; to improve access to longterm care services and coverage; to simplify the administration of health insurance; and to serve other purposes

Question 26

Indemnity plans

Answer 26

Traditional health insurance plans that pay for all or a share of the cost of covered services, regardless of which physician, hospital, or other licensed healthcare provider is used. Policyholders of indemnity plans and their dependents choose when and where to get healthcare services

Question 27

Individual policy

Answer 27

An insurance policy designed specifically for the use of one person (and his or her dependents); it does not offer the benefit of the lower premiums available through a group policy. Often called “personal insurance”

Question 28

Insured

Answer 28

An individual or organization covered by an insurance policy according to the policy terms, usually the individual or group that pays the premiums. Blue Cross/ Blue Shield refers to this person or group as the “subscriber”

Question 29

Managed care plans

Answer 29

An umbrella term for all healthcare plans that provide healthcare in return for preset monthly payments and coordinated care through a defined network of primary care physicians and hospitals

Question 30

Medicaid

Answer 30

A federal- and state-sponsored health insurance program for the medically indigent

Question 31

Medical savings accounts (MSAs)

Answer 31

Tax-deferred bank or savings accounts that are combined with a low-premium, high-deductible insurance policy; they are designed for individuals or families who choose to fund their own healthcare expenses and medical insurance

Question 32

Medicare

Answer 32

A federally sponsored health insurance program for those over age 65 or individuals under age 65 who are disabled

Question 33

Medigap

Answer 33

A term sometimes applied to private insurance products that supplement Medicare insurance benefits

Question 34

Participating provider (PAR)

Answer 34

A physician or other healthcare provider who enters into a contract with a specific insurance company or program and by doing so agrees to abide by certain rules and regulations set forth by that particular third-party payer

Question 35

Policyholder

Answer 35

A person who pays a premium to an insurance company and in whose name the policy is written in exchange for the insurance protection provided by a policy of insurance

Question 36

Preauthorization

Answer 36

A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services or refers a patient to a specialist

Question 37

Premium

Answer 37

The periodic (monthly, quarterly, or annual) payment of a specific sum of money to an insurance company, for which the insurer in return agrees to provide certain benefits

Question 38

Primary care provider (PCP)

Answer 38

A general practice or nonspecialist provider or physician responsible for the care of a patient for some health maintenance organizations. Also called a “gatekeeper”.

Question 39

Referral

Answer 39

An insurance term used when a primary care provider wants to send a patient to a specialist. Typically, the provider must obtain authorization from the insurance carrier in advance to refer a patient

Question 40

Remittance advice (RA)

Answer 40

An explanation of benefits that comes from Medicaid; see explanation of benefits

Question 41

Resource-based relative value scale (RBRVS)

Answer 41

A fee schedule designed to provide national uniform payment of Medicare benefits after being adjusted to reflect the differences in practice costs across geographic areas

Question 42

Rider

Answer 42

A special provision or group of provisions that may be added to a policy to expand or limit the benefits otherwise payable. It may increase or decrease benefits, waive a condition or coverage, or in any other way amend the original contract

Question 43

Self-insured plan

Answer 43

An insurance plan funded by an organization having a large enough employee base that it can afford to fund its own insurance program

Question 44

Self-referral

Answer 44

A patient or insured individual who refers himself or herself to a specialist without requesting the referral from the primary provider, such as a woman seeking an annual gynecologist examination. Managed care guidelines may require the patient to report the self-referral

Question 45

Service benefit plans

Answer 45

Plans that provide benefits in the form of certain surgical and medical services rendered rather than cash. A service benefit plan is not restricted to a fee schedule

Question 46

Third-party administrator (TPA)

Answer 46

An organization that processes claims and performs other business-related functions for a health plan

Question 47

Third-party payor

Answer 47

A person other than the patient, spouse, or parent who is responsible for paying all or part of the patient’s medical costs

Question 48

TRICARE

Answer 48

A government-sponsored program wherein authorized dependents of military personnel receive medical care. Formerly called the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

Question 49

Utilization review

Answer 49

A review of individual cases by a committee to make sure services are medically necessary and to study how providers use medical care resources

Question 50

Workers’ compensation

Answer 50

Insurance against liability imposed on certain employers to pay benefits and furnish care to injured employees and to pay benefits to dependents of employees killed in the course of or because of circumstances arising from their employment

Question 51

Health maintenance organization (HMO)

Answer 51

An organization that provides a wide range of comprehensive healthcare services for a specified group for a fixed, periodic payment. HMOs may be sponsored by the government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies, and hospital-medical plans.