Insurance and Reimbursement Key Terms Flashcards

1
Q

Advance beneficiary notice (ABN)

A

medicare may not cover certain services, pt responsible for bill

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2
Q

assignment of benefits

A

transfer pt legal rights to the provider to collect insurance $ / insurance payment for services will go straight to the provider instead of the patient

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3
Q

balance of billing

A

billing patient for total, or total after insurance

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4
Q

capitation

A

managed care plan that pays certain amount to provider over time for caring for pt

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5
Q

coinsurance

A

agreed amount paid to provider by policy holder

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6
Q

coordination of benefits

A

order in which multiple insurance companies pay (prevents double payments)

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7
Q

copayment/copay

A

part of insurance that patient pays

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8
Q

crossover claim

A

crosses over automatically from 1 coverage to another payment

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9
Q

current procedural terminology (CPT codes)

A

codes used by physicians to define services provided to the patient

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10
Q

deductible

A

amount pt pays before insurance begins paying

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11
Q

dependent

A

spouse or children under insurance plan

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12
Q

diagnosis related groups (DRGs)

A

categories used to determine reimbursements for medicare pt inpatient services

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13
Q

eligibility

A

pt meets the qualifications to be covered by the insurance

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14
Q

explanation of benefits (EOB)

A

statement that accompanies payment, includes date and services paid for

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15
Q

health care savings account (HSA)

A

offered by employer, takes some money out of paycheck and puts into a savings account for medical use

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16
Q

independent practice association (IPA)

A

independent physicians contracted with health maintenance organization to provide services to members

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17
Q

Health Maintenance Organization (HMO)

A

wide range of services through contract with specific group at predetermined rates

18
Q

healthcare common procedure coding

A

assigns alphabetic and numeric code to services and items

19
Q

medicare

A

federally funded insurance for people 65+ or disabled

20
Q

medicare A

A

Portion of Medicare that deals with hospital expenses

21
Q

medicare B

A

physician fees, test, some immunization

22
Q

medicaid

A

Federal and State funded for people with low incomes.

23
Q

medi-medi claim

A

beneficiary with Medicare primary and medicaid as secondary payment. AKA crossover claim

24
Q

medicare administrative contractors (MACs)

A

process claims from providers for services rendered for medicare beneficiary

25
pre-existing condition
medical problems existing before insurance plan's effective date
26
primary and secondary coverage
primary- file 1st secondary-bill remainder of charges
27
centers for medicare and medicaid services (CMS)
mandate use of panels defined by AMA for national standardization of testing
28
plan maximum
highest amount paid by insurance
29
preferred provider organization (PPO)
contract with preferred healthcare provider
30
remittance advice (RA)
medicare administration contract showing payments/ explaining reimbursment
31
usual, customary, reasonable (UCR)
usual cost of similar services in area
32
utilization review (UR)
checks cases to make sure bill were medically necessary
33
coding
assignment of a number to verbal statement or description
34
international classification of diseases (IDC)
transforming verbal description to numeric code
35
nonsufficient funds (NSF)
no money, hot checks
36
collections
acquiring funds that are due
37
credit
record of a payment recieved; balance in one's favor on an account.
38
debit
a charge owed on an account
39
day sheet/ daily journal
a daily record listing all financial transactions and/or patients seen
40
denial
insurance company says they will not pay