Terminology Flashcards
Allowed Charge
The amount that is the most the payer will pay any provider for each procedure or service
Benefits
Payments for medical services
Birthday Rule
A rule that states the insurance policy of a policyholder whose birthday comes first in the year is the primary payer for all dependents
Capitation
A payment structure in which a health maintenance organization prepays an annual set fee per patient to a physician
Clearinghouse
A group that takes nonstandard medical billing software formats and translates them into the standard EDI formats
Coinsurance
A fixed percentage of covered charges paid by the insured person after a deductible has been met
Copayment
A fixed or set amount paid for each healthcare or medical service; the remainder is paid by the health insurance plan. Also called a copay.
Deductibe
A fixed dollar amount that must be paid by the insured before additional expenses are covered by an insurer
Dependents
A person who depends on another person for financial support
Dual Coverage
Term used when a patient is covered by medicare and medicaid
Elective Procedure
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.
Explanation of Benefits
Information that explains the medical claim in detail; also called remittance advice (RA).
Explantation of Payment
Document sent by an insurance carrier when payment is made describing the terms of the payments. Also known as explanation of benefits (EOB) or remittance advice (RA).
Fee-for-Fee-Service
A major type of health plan. It repays policyholders for the costs of healthcare that are due to illness and accidents.
Fee Schedule
A list of the costs of common services and procedures performed by a physician.
Health Maintenance Organization (HMO)
A healthcare organization that provides specific services to individuals and their dependents who are enrolled in the plan. Doctors who enroll in an HMO agree to provide certain services in exchange for a prepaid fee.
Patient Centered Medical Home
A healthcare model designed to change the organization and delivery of primary care in the United States. Primary functions include comprehensive, patient-centered, coordinated care that is accessible and ensures the quality and safety of healthcare provided.
Preauthorization
Authorization or approval for payment from a third-party payer requested in advance of a specific procedure.
Precertification
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.
Preferred Provider Organization
A managed care plan that establishes a network of providers to perform services for plan members.
Premium
The basic annual cost of healthcare insurance
Remittance Advice (RA)
A form that the patient and the practice receive for each encounter that outlines the amount billed by the practice, the amount allowed, the amount of subscriber liability, the amount paid, and notations of any service not covered, including an explanation of why that service is not covered; also called an explanation of benefits.
Resource-Based Relative Value Scale (RBRVS)
The payment system used by Medicare. It establishes the relative value units for services, replacing the providers’ consensus on usual fees.
Third-Party Payer
A health plan that agrees to carry the risk of paying for patient services
Utilization Review (UR)
The process of reviewing medical care in individual cases to be sure that all services provided were medically necessary and that there was appropriate use of medical resources; performed by medical peers and used as a cost control measure by managed care organizations.
