Insurance Flashcards
Insurance coverage for families, children, individuals who are pregnant, older adults who have limited income or access to other health insurance coverage, and those who have certain specified medical needs. Funded by federal and state governments and administered by states.
Medicaid
Insurance coverage in addition to primary and secondary. Covers gaps in primary and secondary insurance coverage
Tertiary insurance
The amount that must be paid before benefits are paid by the insurance
Deductible
Which part of medicare covers pharmaceutical drugs
Medicare part D
When a dependent has more than one health insurance plan, the plan of the parent/guardian whose birthday month and day come first in the calendar year is determined to be the primary plan
Birthday rule
what should be verified if the patient is covered by more than one health plan?
It refers to the sequencing of plans when a patient has more than one insurance plan and it’s necessary to determine which is primary and which is secondary.
Coordination of benefits (COB)
The percentage of the allowed amount the patient will pay once the deductible is met
Coinsurance
A set amount determined by the plan/payer that the patient pays for specified services, usually office visits and emergency department visits
Copayment
A request to determine if a service is covered by the patient’s policy
Precertification
Which part of medicare covers outpatient and professional coverage?
Medicare part B
The amount paid or to be paid the policyholder for the coverage under the contract, usually in periodic installments
Premium
This form is signed by the patient to allow third-party payers to be billed by the medical provider and direct payment made to the medical provider
Assignment of benefits (AOB)
An insurance plan in which a provider signs a contract to participate. The provider agrees to accept a discounted rate for procedures
In-network
The insurance plan that is billed after the primary insurance plan has paid its contracted amount
Secondary insurance
A provision in group health insurance that prevents multiple insurers from paying benefits covered by other policies
Also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim
Coordination of benefits (COB)
a network of physicians, other healthcare practitioners, and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee.
Preferred provider organization (PPO)
A person who signs a contract with a health insurance company and who owns the health insurance policy
Policyholder
The insurance plan responsible for paying health care insurance claims
Primary insurance
Which part of medicare covers hospital coverage
Medicare part A
A medical insurance group that provides coverage of health care services for a period of time and a fixed annual fee
Health maintenance organization (HMO)
This form provides the same information in an electronic format. It usually refers to the provider version as a detailed description of claims payments
Electronic remittance advice (ERA)
Sometimes required by the patient’s insurance company to determine medical necessity for the proposed services
Preauthorization
This insurance serves the military and their qualifying family members, referred to as dependents.
This includes active duty, retired personnel, dependent/spouses, and dependents of service personnel who died while on active duty.
It provides comprehensive coverage for facility costs, outpatient services, professional medical services, and medication costs.
TRICARE
This form shows the claim adjudication as well as the results.
This can include denials, billed amounts, allowed amounts, covered services, and patient financial responsibilities of deductible and coinsurance.
Explanation of benefits (EOB)
This is used when medicare may not consider tests, procedures, or services to be medically necessary, and the patient must sign this form after they are informed of this and agree (or disagree) to be financially responsible in the event medicare determines that the service is not medically necessary.
Advanced beneficiary notice (ABN)
Which part of medicare covers managed care plans?
Medicare part C
Medicare supplemental health insurance for medicare beneficiaries, which may include payment of medicare deductibles, coinsurance, balance bills, or other services not covered by medicare.
Medigap, medi medi
insurance provided by the federal government for people aged 65 and up, people with certain disabilities, and people with end-stage renal disease.
Medicare
