insurance terms MA116, 117 Flashcards
abuse
purposely causes harm
adjudicate
to settle or determine judicially
advanced beneficiary notice ABN
a notice that healthcare facilities send out when the accepted payment is excepted to be denied
approved/allowed amount
the max your insurance company will pay
assignments of benefits
an legal agreement that allows a patient healthcare provider to receive payment from the insured party
audit
a process completed before claims are examined for accuracy
beneficiary
Designated person to receive funds in a life insurance policy
benefits
the 10 categories
included in your essential health care plan
birthday rule
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
capitation
a payment arrangement for healthcare providers
claim
term used when filling insurance documents
clean claim
when all information is correct that is filled on the insurance form
Center for Medicare and Medicaid severs (CMA)
federal agency that providers healthcare thur Medicaid, Medicare, and children’s health insurance programs (CHIP)
Co-insurance
the amount you pay for covered health care after you meet your deductible
Co payment
a set dollar amount that is required to pay for each office visit
The Current Procedural Terminology (CPT)
an online coding journal
deductible
the amount the policy holder is required to pay before the insurance company will start to pay
demographic
personally information about the patient
direct billing
a process where an insurance company allows the provider to electorally submit claims directly to the company
effective date
when coverage begans
elective procedure
a medical surgical intervention that isnt medically necessary
eligibility
meeting the requirements to participate in the healthcare plan
encounter form
a medical document that records details of a patients visit to a healthcare providers
exclusion
when insurance covered does not apply to certain events
explanation of benefits (EBO)
to inform the patients with cost for their medical care
federal tac ID/ employment identification number (EIN)
social security number
fee schedule
is a single national number to all services that included a conversion factor
fraud
knowing and willing to execute a scheme
group policy
when a employer can pick and choose the benefits it wants for their employees
primary care physician (PCP)/ gatekeeping
a general practice or non specialist provider, that is responsible for the patients care
health insurance exchange
an individual policy can cover one person or family
health maintenance organization (HMO)
are health plans that are regulated by HMO laws, which are required them to preventive care as a part of there benefits packages
ICD
international classification of diseases
independent practice association (IPA)
a group of independent physician practices that work together to improve efficiency and pursue
indigent
the elderly, military, and government employees
managed care organization (MCO)
a healthcare company or plan that manages healthcare services for its members to control cost while maintaining or improving the quality of care
Medicaid
government insurance meant for low income
medicare
insurance for people over the age of 65
Medicare part a
covers inpatients and hospitals chargers
medicare part B
covers primary care and specialist
medcare part c
option for people that want to combine parts A and B to have more access to extra benefits
medicare part D
is a prescription drug program that has their own monthly premium
medigap (MG)
a policy that can help you pay other healthcare cost
non covered services
things that arent covered in the insurance plans
national provider identifier (NPI)
unique identifier given to each healthcare that is used in administrative transactions
online insurance web portal
where you can verify insurance edibility, benefits, and exclusions prior to the patients appointment
out of pocket expense
portion require for the patient to pay
participating providers
providers listed on PPO
(preferred provider organization) that has the accepted providers and healthcare facilities
policy
a legal contract and will stay in place as long as the premium is being paid
precertification/perautorziation
a document a provider is required to submit to show that the patient needs the medical producer
premium
the periodic (monthly, quarterly, or annual) payment for you insurance
primary policy
the patients primary insurance
provider network
an approved list of physician’s, hospitals, and other providers
provider web portal
where all claims are submitted too
resources based relative value scale (RBRUS)
a system used to determine how much providers should be paid for services rendered
referral
an order from a pcp for the patient to see a specialist
secondary policy
the 2nd policy listed on the patients insurance
TRICARE
an program for active duty and retired military members of uniformed services and their families
verification of benefits
A process that determines what patients insurance will cover
workers compensation
is a publicy sponsored program system that pays monetary benefits to workers who become injured or disable in the course of their employment
