medical insurance terms

Question 1

Health Plan

Answer 1

insurance for patient

Question 2

indemnity Plan

Question 3

managed care

Answer 3

lower premium, restricted drs., diagnostic in exchange for lower premium

Question 4

MCO

Answer 4

Managed Care Organization

Question 5

Medical Coder

Question 6

Medical necessity

Question 7

Network

Question 8

noncovered services

Question 9

out-of-network

Question 10

out of pocket

Answer 10

$ patient has to pay before deductible is met and all copays and

Question 11

participation

Question 13

Abuse

Answer 13

action that improperly uses another person’s resources

Question 14

Audit

Answer 14

Methodical review, in medical insurance, a formal examination of a physician’s account or patient medical records

Question 15

breach

Answer 15

broken agreement - an impermissible use or disclosure under the Privacy Rule reputational or other harm to the affect person

Question 16

Authorization

Answer 16

from insurance company stating that they will pay their portion of the bill and that the procedure or visit is something they find necessary

Question 17

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

Answer 17

same

Question 18

Clearinghouse

Answer 18

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

Question 19

Covered Entity

Answer 19

Under HIPAA, a health plan, clearinghouse, or provider who transmits any health information in electronic form in connection with HIPAA transaction

Question 20

Encounter

Answer 20

meeting or visit patient to dr

Question 21

electronic data interchange (EDI)