Health insurance terminology Flashcards
Premium
The amount the policy holder pays the insurance company to keep the policy in effect
Subscriber/policy holder
The person who owns the policy
Insured/Beneficiaries
The person(s) covered under the insurance policy
Guarantor
Person who is responsible for the out of pocket expenses.
In network/participating provider
Provider who has a contract with the insurance company. They accept the allowed amount by the insurance and takes it as full payment.
Out of network/Non participating provider
Not under contract. can balance bill
Balance bill
Patient/insured is billed the difference between what the services cost and what insurance will pay
Allowed amount
The amount that the participating provider and insurance company agrees upon.
UCR
= The maximum amount an insurer will pay for a given service.
Deductible
Amount that must be paid before an insurer will cover expenses. In order for benefits to begin, the patient must pay their deductibles
RENEWS every year
Coinsurance
a percentage that the patient is responsible for paying
co-payment
A set amount that must be payed by the insured for a specific service.
pre-existing condition
Medical condition that existed before obtaining health insurance
Exclusions
Items that may not be paid for by insurance.
Precertification
Confirming that a service is a benefit covered under the policy
Preauthorization
Prior approval that insurance is covering service and that it’s a necessity
NO PREAUTH= NO INSURANCE
Predetermination
Determining how much insurance will pay
Coordination of Benefits
To establish the order that health insurance plans pay claims when more than one plan exists (figuring out primary ad secondary insurance)
Birthday rule:
The primary and secondary insurance for a child is determined by the parents birthdate
Third-party payer/ third-party reimbursement
Indicates that a payment is coming from someone other than the patient
Third-party liability
Legal obligation of third parties to pay what is required of them according the the plan
Fee schedule
Predetermined payment amounts for service
Capitation
When providers are prepaid a fixed amount every month depending on how many patients they have and the services they provide.
open-enrollment
The time period in which an individual can sign-up for or change/disenroll from their insurance.
Qualifying event
A special event that allows someone to sign up or change/disenroll from their insurance
