insurance/admin terms

Question 1

advance beneficiary notice (ABN)

Answer 1

A form provided to the patient when the provider believes Medicare will probably not pay for services received.

Question 2

Allowed amount

Answer 2

The maximum amount a third party payer will pay for a particular procedure or service.

Question 3

Copayment

Answer 3

An amount of money that is paid at the time of medical service.

Question 4

Coinsurance

Answer 4

A policy provision frequently found in medical insurance whereby the policy holder and the insurance company share the cost of covered losses in a specified ratio; such as 80:20.

Question 5

Deductible

Answer 5

A specific amount of money a patient must pay out of pocket before the insurance carrier begins paying.

Question 6

Explanation of Benefits (EOB)

Answer 6

A statement from the insurance carrier detailing what was paid, denied, or reduced in payment; also contains information about amounts applied to the detuctible, coinsurance, and allowed amounts.

Question 7

Participating provider (PAR)

Answer 7

Providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer.

Question 8

Medicare

Answer 8

generally covers patients age 65 and older by Part A (Hospitalization) or Part B (routine medical office visits) benefits.

Question 9

Tricare

Answer 9

authorizes dependents of military personnel to receive treatment from civilian providers at the expense of the federal government

Question 10

ChampVA

Answer 10

covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities.

Question 11

Medicaid

Answer 11

providers health insurance to the medically indigent population through a cost-sharing program between federal and state governments for those who meet specific eligibility criteria.

Question 12

Managed care

Answer 12

is an umbrella term for plans that provide healthcare in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals.

Question 13

Worker’s Compensation

Answer 13

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.

Question 14

CMS-1500 form

Answer 14

health ins claim form for claims submitted by provider or supplier. The MA must have all the info needed to complete the form, including the patient and guarantors demographic and insurance info; diagnostic test, treatment or procedure information; and billing information. This form has 33 block or items which are divided into 3 sections.
*Carrier block - contains address of the ins carrier and is located at the top of the form.
*patient/insured section - patient info or insured. Boxes 1-13.
*Physician/supplier section - physician/supplier information. Boxes 14-33.