Medical Insurance & Billing Flashcards
Who is a first party payor?
patient
Who is a second party payor?
healthcare provider
Who is a third part payor?
health plan (insurance)
What is a deductible?
amount of money a patient must pay out of pocket before insurance begins paying
What is a coinsurance?
policyholder and insurance company share the cost of services (ex. 80:20)
What is a copayment?
amount of money paid at the time of service
- ex. primary care: $20
- ex. medications: $35
What is an assignment of benefits?
form signed by the patient to allow the provider to be paid directly by the insurance company
What is a participating provider?
providers that agree to write off the difference between that amount charged and the allowed amount by the insurance company
What is allowed amount?
maximum amount the insurance company will pay for a service or product
What is an advanced beneficiary notice? (ABN)
form given to patient when the provider believes medicare will not cover services
- patient must pay
What is an explanation of benefit? (EOB)
statement from insurance company to patient outlining amounts billed, amounts allowed, amounts applied to deductible, coinsurance, and copays
What is preauthorization? (precertification)
process of contacting the insurance plan to see if a procedure is a covered service under the patient’s insurance plan
Who is medicare for?
patient’s over 65 y/o
What is medicare part A?
hospitalization
What is medicare part b?
routine medical office visits and outpatient services
What is medicare part c?
optional additional coverage offered by private companies approved by medicare
What is medicare part D for?
medications
Who is medicaid for?
covers low income and mentally indigent
Who is tricare for?
military personnel and dependants
Who is CHAMPVA for?
surviving spouses and dependent children of veterans who have died due to service related disabilities
What is CHIP? Who is it for?
children’s health insurance program
- low-cost health coverage to children in families that earn too much money to qualify for medicaid
What is workers compensation?
covers workers against lost wages due to accidents on the job
What is HMO?
contracts with providers and hospitals to provide preventative and acute care
- requires referrals to specialists
- requires preauthorization
- requires PCP
What is PPO?
- no referrals needed
- in-network providers
What is fee-for-service?
- policy lists covered medical services
- amount charged for services is controlled by the physician
- amount paid for services is controlled by the insurance carrier
What is pay-for-performance?
compensates providers only if certain measures are met for quality and efficiency
What is capitation?
patient’s are assigned a per member per month payment based on age, race, sex, lifestyle, medical history
What form is needed for electronic claim transmission?
CMS-1500
What is in section 1 of the CMS-1500 form?
address of insurance carrier
- top of form
What is in section of CMS-1500 form?
patient/insured section
- information about patient or covered person
- blocks 1-13
What is in section 3 of CMS-1500 form?
- physician/supplier section
- boxes 1-33
What is account receivable?
money owed to the provider for services rendered
What is account payable?
debt incurred by not paid
- supplies or utilities
Who is a guarantor?
person with financial responsibility for the patient
