Insurance Flashcards
Advanced Beneficiary Notice (ABN)
A form provided to the patient when the provider believes Medicare will probably not pay for services received
Allowed Amount
The maximum amount a third-party payer will pay for a particular procedure or service
Amount insurance company allows Dr to charge for service
Copayment
A fixed amount, out of pocket expense paid at the time of medical service
Coinsurance
A policy provision in which the policyholder and the insurance company share the cost of covered medical services in a specified ratio such as 80:20
% of visit out of pocket expense
Deductible
a specific amount of money a patient must pay out of pocket before the insurance carrier begins paying
Explanation of Benefits (EOB)
A statement from an insurance carrier describing what services were paid, denied, or reduced in payment
And also contains info about amounts applied to deductible, coinsurance, and allowed amounts
Participating Provider (PAR)
Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer
Federal and State government insurance plans
-Medicare
-Medicaid
-Tricare
-CHAMPVA
-managed care plans
-workers’ compensation
Medicare
generally covers patients age 65 and older by Part A (hospitalization) or Part B (routine medical office visits) benefits
TRICARE
authorizes dependents of military personnel to receive treatment from civilian providers at the expense of the federal government
CHAMPVA
covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities
Medicaid
provides health insurance to the medically indigent population through a cost-sharing program between federal and state governments for those who meet specific eligibility criteria
Managed Care
an umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals
Workers Compensation
protects wage earners against the loss of wages and the cost of medical care resulting from an occupational accident or disease as long as the employee is not proven negligent
Private Insurances
-Blue Cross Blue Shield (America’s oldest and largest system)
-Aetna
-United Healthcare
Healthcare Delivery Models
organization of individuals,establishments, and resources to deliver healthcare services and meet the health needs of specific populations
HMO
Patients are restricted to network and may not see a specialist without a a referral or acquire coverage for service received outside of network
PPO
preferred provider organization
Greater flexibility by having freedom to visit any provider but has increased cost and decreased coverage for out of network
CMS-1500 Form
Health insurance claim form
the standard form used by health-care providers to bill for services, including disease state management services
CMS-1500 Form Sections
Form has 33 blocks or items divided into 3 sections:
Section 1: Carrier Block
Section 2: Patient/Insured Section
Section 3: Physician/Supplier Section
Section 1: Carrier Block
contains the address of the insurance carrier and is located at the top of the form
Section 2: Patient/Insured Section
contains information about the patient or insured (if other than the patient); includes boxes 1 through 13.
Section 3: Physician/Supplier Section
contains information about the physician or supplier: includes boxes 14 through 33.
