insurance terms MA116, 117

Question 1

abuse

Answer 1

purposely causes harm

Question 2

adjudicate

Answer 2

to settle or determine judicially

Question 3

advanced beneficiary notice ABN

Answer 3

a notice that healthcare facilities send out when the accepted payment is excepted to be denied

Question 4

approved/allowed amount

Answer 4

the max your insurance company will pay

Question 5

assignments of benefits

Answer 5

an legal agreement that allows a patient healthcare provider to receive payment from the insured party

Question 6

audit

Answer 6

a process completed before claims are examined for accuracy

Question 7

beneficiary

Answer 7

Designated person to receive funds in a life insurance policy

Question 8

benefits

Answer 8

the 10 categories
included in your essential health care plan

Question 9

birthday rule

Answer 9

when a child has parents that both have different insurance policy the patrent that birthday falls first in the calendar year becomes the primary insurance and the other becomes the secondary

Question 10

capitation

Answer 10

a payment arrangement for healthcare providers

Question 11

claim

Answer 11

term used when filling insurance documents

Question 12

clean claim

Answer 12

when all information is correct that is filled on the insurance form

Question 13

Center for Medicare and Medicaid severs (CMA)

Answer 13

federal agency that providers healthcare thur Medicaid, Medicare, and children’s health insurance programs (CHIP)

Question 14

Co-insurance

Answer 14

the amount you pay for covered health care after you meet your deductible

Question 15

Co payment

Answer 15

a set dollar amount that is required to pay for each office visit

Question 16

The Current Procedural Terminology (CPT)

Answer 16

an online coding journal

Question 17

deductible

Answer 17

the amount the policy holder is required to pay before the insurance company will start to pay

Question 18

demographic

Answer 18

personally information about the patient

Question 19

direct billing

Answer 19

a process where an insurance company allows the provider to electorally submit claims directly to the company

Question 20

effective date

Answer 20

when coverage begans

Question 21

elective procedure

Answer 21

a medical surgical intervention that isnt medically necessary

Question 22

eligibility

Answer 22

meeting the requirements to participate in the healthcare plan

Question 23

encounter form

Answer 23

a medical document that records details of a patients visit to a healthcare providers

Question 24

exclusion

Answer 24

when insurance covered does not apply to certain events

Question 25

explanation of benefits (EBO)

Answer 25

to inform the patients with cost for their medical care

Question 26

federal tac ID/ employment identification number (EIN)

Answer 26

social security number

Question 27

fee schedule

Answer 27

is a single national number to all services that included a conversion factor

Question 28

fraud

Answer 28

knowing and willing to execute a scheme

Question 29

group policy

Answer 29

when a employer can pick and choose the benefits it wants for their employees

Question 30

primary care physician (PCP)/ gatekeeping

Answer 30

a general practice or non specialist provider, that is responsible for the patients care

Question 31

health insurance exchange

Answer 31

an individual policy can cover one person or family

Question 32

health maintenance organization (HMO)

Answer 32

are health plans that are regulated by HMO laws, which are required them to preventive care as a part of there benefits packages

Question 33

ICD

Answer 33

international classification of diseases

Question 34

independent practice association (IPA)

Answer 34

a group of independent physician practices that work together to improve efficiency and pursue

Question 35

indigent

Answer 35

the elderly, military, and government employees

Question 36

managed care organization (MCO)

Answer 36

a healthcare company or plan that manages healthcare services for its members to control cost while maintaining or improving the quality of care

Question 37

Medicaid

Answer 37

government insurance meant for low income

Question 38

medicare

Answer 38

insurance for people over the age of 65

Question 39

Medicare part a

Answer 39

covers inpatients and hospitals chargers

Question 40

medicare part B

Answer 40

covers primary care and specialist

Question 41

medcare part c

Answer 41

option for people that want to combine parts A and B to have more access to extra benefits

Question 42

medicare part D

Answer 42

is a prescription drug program that has their own monthly premium

Question 43

medigap (MG)

Answer 43

a policy that can help you pay other healthcare cost

Question 44

non covered services

Answer 44

things that arent covered in the insurance plans

Question 45

national provider identifier (NPI)

Answer 45

unique identifier given to each healthcare that is used in administrative transactions

Question 46

online insurance web portal

Answer 46

where you can verify insurance edibility, benefits, and exclusions prior to the patients appointment

Question 47

out of pocket expense

Answer 47

portion require for the patient to pay

Question 48

participating providers

Answer 48

providers listed on PPO (preferred provider organization) that has the accepted providers and healthcare facilities

Question 49

policy

Answer 49

a legal contract and will stay in place as long as the premium is being paid

Question 50

precertification/perautorziation

Answer 50

a document a provider is required to submit to show that the patient needs the medical producer

Question 51

premium

Answer 51

the periodic (monthly, quarterly, or annual) payment for you insurance

Question 52

primary policy

Answer 52

the patients primary insurance

Question 53

provider network

Answer 53

an approved list of physician's, hospitals, and other providers

Question 54

provider web portal

Answer 54

where all claims are submitted too

Question 55

resources based relative value scale (RBRUS)

Answer 55

a system used to determine how much providers should be paid for services rendered

Question 56

referral

Answer 56

an order from a pcp for the patient to see a specialist

Question 57

secondary policy

Answer 57

the 2nd policy listed on the patients insurance

Question 58

TRICARE

Answer 58

an program for active duty and retired military members of uniformed services and their families

Question 59

verification of benefits

Answer 59

A process that determines what patients insurance will cover

Question 60

workers compensation

Answer 60

is a publicy sponsored program system that pays monetary benefits to workers who become injured or disable in the course of their employment