MA103K Unit I (Test terms) Flashcards
HMO
Health Maintenance Organization(managed care plan)
IPA(Independent Practice Association)
A type of HMO in which contracted services are provided by providers who maintain their own offices
Group Health Insurance
insurance offered to all employees by an employer
Individual Health Insurance
insurance purchased by an individual or family who does not have access to group health insurance
Birthday rule
primary coverage for dependents by the month and day of parent’s birthday-whichever’s first
PPO
Preferred Provider Organization(another type of HMO)
Deductible
an amount to be paid before an insurance will pay
Preexisting condition
a condition that existed before the insured’s policy was issued
Assignment of Benefits
the authorization , by signature of the patient, for payment to be made directly by the patient’s insurance to the provider for services
CHAMPUS
(TRICARE) established to aid dependents of active , retired, or dead service member with a supplement for medical care in military or health service facilities
CHAMPVA
Established in 1973 for the spouses and dependent children of veterans who have total, permanent, or service related disabilities.
COB(Coordination of Benefits)
Procedures insurers use to avoid duplication of payment on claims when the patient has more than one policy
Copayment or coinsurance
amount a patient must pay toward the charge for professional service rendered at the time of service
Effective date
a date when insurace policy takes effect
Gatekeeper
(PCP) Primary Care Provider who are responsible for coordinating the patient’s care to specialists, hospital admissions, and so on
Policy
overall plan
Subscriber
a person who has been insured; and insurance policy holder
Superbill
itemized form utilized by heath providers for reflecting rendered services
Usual fee
amount commonly charged for a particular medical services by providers in a specific geographical area
-algia
pain
hyper-
excessive
-osis
abnormal condition
-rrhage
bleeding
-rrhea
discharge
dys-
difficult
-ostomy
surgical creation, opening to the body
-sclerosis
abnormal hardening
-ectomy
surgical removal
hypo-
deficient
-plasty
surgical repair
-rrhaphy
surgical suturing
-rrhexis
rupture
-itis
inflammation
-otomy
cutting, surgical incision
Staff-Model
are plans in which the providers are employed by the HMO, and all the services are provided by the practice.
Group-Model
multispecialty practices contracted to provide health care services to members
workers’ compensation
government program that provides insurance coverage for those who are injured on the job
Medicaid
a joint funding program by federal and state government for the medical care of low-income patients on public assistance
Manage care
a system of health care that integrates the delivery and payment of health care for covered persons
Precertification
seeking approval for a treatment
Utilization review
a method of controlling health care costs by reviewing services to be provided to members of a plan to determine the appropriateness and medical necessity of the care prior to the delivery of the care
Service area
the geographic area served by an insurance carrier
