Health Insurance & Billing Flashcards
Centers for Medicare and Medicaid Services -basic standard claim form used by health care professionals to request reimbursement for services provided to patients
CMS-1500
an itemized form of services submitted to insurance carriers for reimbursement of rendered services -a CCMA would also use this form to check patients out after an office visit
Encounter Form (Superbill)
allows a patient access to his or her own medical records and allows the patient control over to whom those records are released
Release of Information Form
managed care organization of providers, hospitals and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at reduced rates to the insurer’s or administrator’s clients
Preferred Provider Organization (PPO)
a federal and state program that helps with medical costs for some people with limited income and resources (the medically needy)
Medicaid
federal health insurance program that generally covers those over 65, the disabled and those with end-stage renal disease -considered an entitlement because most of those in the system have paid into the system through payroll tax
Medicare
healthcare for military personnel and their dependents to receive care from civilian providers at the expense of the federal government
Tricare
wage replacement and medical benefits for those injured on the job
Workers’ Compensation
waiver of liability; a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service (the patient will then be responsible for paying the bill)
Advance Beneficiary Notice (ABN)
an amount a policyholder is financially responsible for according to their insurance policy the policy holder must meet a specified amount before the insurance company will pay their portion
Coinsurance
a specified sum of money based on the patient’s insurance policy benefits due at the time of service
Copay
specific amounts of money a patient must pay out-of-pocket before the insurance carrier begins paying for services in a calendar year
Deductible
a statement detailing what services were paid, denied or reduced in payment by the patient’s insurance company
Explanation of Benefits (EOB)
a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary
Preauthorization
the process of obtaining eligibility, certification or authorization and collecting information from the health plan prior to impatient admissions and selected ambulatory procedures and services
Precertification
