Med Office 1

Question 1

allowed charge (allowable amount)

Answer 1

maximum amount of money that a 3rd party payers allow for a specific procedure

Question 2

authorization

Answer 2

number given by the insurance company authorizing approval of a procedure or service

Question 3

beneficiary

Answer 3

individual entitled to receive benefits from an insurance policy or gram or a governmental entitlement program offering healthcare benefits

Question 4

other names for beneficiary

Answer 4

participant
subscriber
dependent 
enrollee
member

Question 5

benefits

Answer 5

amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage

Question 6

birthday rule

Answer 6

insurance plan of the policyholder whose birthday comes first in the calendar year becomes the primary insurance

Question 7

captiation

Answer 7

a fixed amount of money is reimbursed to the provider no matter what services were received or how many visits were made

Question 8

carriers

Answer 8

insurance terms companies that assume the risk of an insurance policy

Question 9

CHAMPUS

Answer 9

civilian health and medical program of the uniformed services

Question 10

CHAMPVA

Answer 10

coverage for those insured in the military

NOT ELIGIBLE FOR TRICARE

Question 11

co-insurance

Answer 11

80/20

Question 12

commercial insurance plans

Answer 12

reimburse the insured for expenses resulting from illness according to a specific fee schedule as outlined in the insurance policy and on a fee for service basis

Question 13

other name for commercial insurance plan

Answer 13

private insurance

Question 14

co-payment

Answer 14

sum of money that is paid at the time of medical service

Question 15

deductibles

Answer 15

money a pt must pay out of pocket before the insurance begins paying

Question 16

dependents

Answer 16

spouse, children, domestic partner designated by the insured who are covered under the plan

Question 17

disability income insurance

Answer 17

provides periodic payments to replace income when an insured person is unable to work from illness/injury

Question 18

effective date

Answer 18

date on which an insurance policy or plan takes effect so that benefits are payable

Question 19

eligibility

Answer 19

whether a pts insurance coverage is in effect and eligible for payment of insurance benefits

Question 20

exclusions

Answer 20

limitations on an insurance contract for which benefits aren’t payable

Question 21

explanation of benefits

Answer 21

letter from the insurance carrier describing what was paid, denied, or reduced in payment

Question 22

explanation of medicare benefits

Answer 22

explanation of benefits from medicare

Question 23

fee for service

Answer 23

established schedule of fees set for services performed by providers and paid by the pt

Question 24

government plans

Answer 24

programs or plan that are sponsored by the state or federal government
(Medicare, Medicaid)

Question 25

group policy

Answer 25

a number of people under a single master contract issued to their employer

Question 26

guarantor

Answer 26

person responsible for paying a medical bill

Question 27

health maintenance organziation

Answer 27

managed care plan | specific providers that you have to see, no coverage for out of network

Question 28

indemnity plans

Answer 28

health insurance plans that pay for all or a share of the cost of covered services, regardless of which physician is used

Question 29

insured

Answer 29

ind. or group covered by an insurance policy

Question 30

managed care plans

Answer 30

hospitals and docs in a contract within a defined network of facilities w/ a preset monthly payment

Question 31

medical savings accounts

Answer 31

low premium, high deductible | people who want to fund their own expenses

Question 32

medicaid

Answer 32

for those who can't afford health insurance | managed by the state

Question 33

medicare

Answer 33

65+, disable or blind, kidney failure

Question 34

medicare part A

Answer 34

hospital, hospice, skilled nursing

Question 35

medicare part B

Answer 35

doctors visits, outpatient hospital, DME

Question 36

medicare part C

Answer 36

supplemental plan

Question 37

medicare part D

Answer 37

prescriptions

Question 38

medigap

Answer 38

private insurance products that supplement medicare insurance benefits

Question 39

participating provider

Answer 39

provider who enter into a contract with a specific insurance company and agree to abide by certain rules

Question 40

policyholder

Answer 40

person who pays a premium to an insurance company

Question 41

premium

Answer 41

money you pay to have insurance (deducted from check or payment is made)

Question 42

primary care provider

Answer 42

provider responsible for the care of a patient for some health maintenance orgainzations

Question 43

referral

Answer 43

PCP to a specialist

Question 44

remittance adivce

Answer 44

explanation of benefits from medicaid

Question 45

resource based relative value scale

Answer 45

provide national uniform payment of medicare benefits after adj to reflect the difference in practice costs across geographic areas

Question 46

self insured plan

Answer 46

plan funded by an organ. having a large enough employee base that it can afford to fund its own insurance program

Question 47

service benefit plans

Answer 47

plans that provide benefits in the form of certain surgical services other than cash

Question 48

3rd party administrator

Answer 48

processes claims and performs other business related functions for a health plan

Question 49

3rd party payer

Answer 49

entities that make payment on an obligation or debt but aren't parties to the contract that created the debt

Question 50

TRICARE

Answer 50

government assistance for military BEST

Question 51

utilization review

Answer 51

review of individual cases by a committee to make sure that services are medically necessary

Question 52

works compensation

Answer 52

protects employees against the loss of wages and the cost of medical care resulting from an occup. accident

Question 53

DRG's

Answer 53

reimburses from medicare part A

Question 54

PPO

Answer 54

you can see any provider, however better benefit if you stay in network