medical insurance terms Flashcards
Health Plan
insurance for patient
indemnity Plan
managed care
lower premium, restricted drs., diagnostic in exchange for lower premium
MCO
Managed Care Organization
Medical Coder
Medical necessity
Network
noncovered services
out-of-network
out of pocket
$ patient has to pay before deductible is met and all copays and
participation
Abuse
action that improperly uses another person’s resources
Audit
Methodical review, in medical insurance, a formal examination of a physician’s account or patient medical records
breach
broken agreement - an impermissible use or disclosure under the Privacy Rule reputational or other harm to the affect person
Authorization
from insurance company stating that they will pay their portion of the bill and that the procedure or visit is something they find necessary
Centers for medicare & Medicaid svc (CMS) - fed agency within the Dept. of Health and Human Services (HHS) that runs medicare, medicaid clinical laboratories (under the CLIA program) and other government health programs
same
Clearinghouse
a company that washes and flags electronic bills sent over by billing companies- service that will flag the “dirty” claims and send back until we fix errors and then they are clean claims
Covered Entity
Under HIPAA, a health plan, clearinghouse, or provider who transmits any health information in electronic form in connection with HIPAA transaction
Encounter
meeting or visit patient to dr
electronic data interchange (EDI)
