Insurance Flashcards
- TRICARE
For active duty and dependents
- CHAMPVA
For retired veterans and dependents.
HMO
Health Maintenance Organization: Comprehensive and affordable, needs referrals.
PPO
Preferred Provider Organization: More expensive, more choices, no referral needed.
POS
Point of Service: Most expensive, most choices, a mix of PPO and HMO.
Types of Health Insurance Plans
- Individual policies, government policies, group policies
Medicaid
- For indigent, poor, low income.
- Federally and state-funded.
- SCHIP
State Children’s Health Insurance Program- Covers uninsured children.
- Affordable Care Act:
Offers health insurance options through marketplaces.
UB-04
Billing form for institutional locations.
CMS
Oversees Medicare and Medicaid.
Subscriber number
insurance ID
- Preauthorization:
Formal approval for test/procedure coverage
- Waiting period:
Time when certain problems aren’t covered.
ABN
Advanced Beneficiary Notice: Given to patients if a service may be declined.
Allowable amount
Limit on reimbursement for a service or procedure
AOB
Assignment of Benefits: Authorizes benefits to be sent directly to providers.
Birthday Rule
Determines primary plan holder in dual coverage
- Co-payment
Fixed fee for a service collected at each visit.
- Deductible:
Amount patient pays before insurance coverage.
- Coinsurance:
Cost-sharing after deductible, percentage-based.
EOB
Explanation of Benefits: Records patient fees and claim adjustments.
- Out-of-pocket expense:
Patient’s responsibility for healthcare expenses.
- Out-of-pocket maximum:
Predetermined amount after which insurance pays 100%.
