OAD216 Ch. 17

Question 1

Premium

Answer 1

the basic annual cost of healthcare insurance

Question 2

Benefit

Answer 2

payments for medical services

Question 3

Lifetime Maximum

Answer 3

a total sum the health plan will pay out over the patients lifetime

Question 4

Deductible

Answer 4

a fixed dollar amount that must be paid by the insured before additional expenses are covered by an insurer

Question 5

CoInsurance

Answer 5

a fixed percentage of covered charges paid by the insured person after a deductible has been met

Question 6

Copayment

Answer 6

a fixed or set amount paid for each healthcare or medical service; the remainder is paid by the health insurance plan

Question 7

Exclusions

Answer 7

non-covered expenses that may not be covered under the insureds contract

Question 8

Formulary

Answer 8

a list of approved brands

Question 9

Elective Procedure

Answer 9

A medical procedure that is not required to sustain life but is requested for payment to the third-party payer by the patient or physician. Some elective procedures are paid for by third-party payers, whereas others are not.

Question 10

Precertification

Answer 10

A determination of the amount of money that will be paid by a third-party payer for a specific procedure before the procedure is conducted.

Question 11

Preauthorization

Answer 11

Authorization or approval for payment from a third-party payer requested in advance of a specific procedure.