Terms Flashcards
Deductible
The amount you pay for covered health care services before your insurance plan starts to pay (https://www.healthcare.gov/glossary)
Medicaid
Insurance program that provides free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities (https://www.healthcare.gov/glossary)
Medicare
A federal health insurance program for people 65 and older and certain younger people with disabilities (https://www.healthcare.gov/glossary)
Claim
A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered (https://www.healthcare.gov/glossary)
Copayment (Copay)
A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible (https://www.healthcare.gov/glossary)
Health insurance
A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium (https://www.healthcare.gov/glossary)
Health coverage
Legal entitlement to payment or reimbursement for your health care costs, generally under a contract with a health insurance company, a group health plan offered in connection with employment, or a government program like Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP) (https://www.healthcare.gov/glossary)
Out-of-pocket costs
Your expenses for medical care that aren’t reimbursed by insurance. Includes deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered (https://www.healthcare.gov/glossary)
Preferred Provider Organization (PPO)
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost (https://www.healthcare.gov/glossary)
Flexible Spending Account (FSA)
An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, insulin, and medical devices (https://www.healthcare.gov/glossary)
Hospice
Services to provide comfort and support for persons in the last stages of a terminal illness and their families (https://www.healthcare.gov/glossary)
Pre-existing condition
A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies can’t refuse to cover or charge you more (https://www.healthcare.gov/glossary)
Waiting period
The time that must pass before coverage can become effective for an employee or dependent who is otherwise eligible for coverage under a job-based health plan (https://www.healthcare.gov/glossary)
UCR (Usual, Customary, and Reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service (https://www.healthcare.gov/glossary)
TRICARE
A health care program for active-duty and retired uniformed services members and their families (https://www.healthcare.gov/glossary)
Specialist
A physician that focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions (https://www.healthcare.gov/glossary)
Referral
A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), necessary before you can get medical care from anyone except your primary care doctor (https://www.healthcare.gov/glossary)
Out of network
A doctor, hospital or other healthcare provider who is not part of an insurance plan, doctor or hospital network (https://www.healthcare.gov/glossary)
Network
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services (https://www.healthcare.gov/glossary)
Generic drug
A prescription drug that has the same active-ingredient formula as a brand-name drug (https://www.healthcare.gov/glossary)
Formulary
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list (https://www.healthcare.gov/glossary)
Coordination of benefits
A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim (https://www.healthcare.gov/glossary)
Coinsurance
The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible (https://www.healthcare.gov/glossary)
Benefits
The health care items or services covered under a health insurance plan (https://www.healthcare.gov/glossary)
Allowed amount
The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate” (https://www.healthcare.gov/glossary)
Attending physician
The doctor who orders your treatment and who is responsible for your care (https://www.uwmedicine.org/patient-resources/billing-and-insurance-2/glossary)
Same-day surgery
A surgery performed as an outpatient service (https://www.uwmedicine.org/patient-resources/billing-and-insurance-2/glossary)
Congenital
existing at or dating from birth (https://www.merriam-webster.com/dictionary)
Histological
related to tissue
Children’s Health Insurance Program (CHIP)
Insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, covers pregnant women (www.healthcare.gov/glossary)
Emergency room care
Emergency services you get in an emergency room (www.healthcare.gov/glossary)
Guaranteed issue
A requirement that health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services (www.healthcare.gov/glossary)
Guaranteed renewal
A requirement that your health insurance issuer must offer to renew your policy as long as you continue to pay premiums (www.healthcare.gov/glossary)
Summary of benefits and coverage (SBC)
An easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between health plans. You can compare options based on price, benefits, and other features that may be important to you (www.healthcare.gov/glossary)
Uncompensated care
Health care or services provided by hospitals or health care providers that don’t get reimbursed. Often arises when people don’t have insurance and cannot afford to pay the cost of care (www.healthcare.gov/glossary)
When can you apply for Medicaid?
You can apply anytime. If you qualify, your coverage can begin immediately, any time of year (www.healthcare.gov/glossary)
When can you apply for CHIP?
You can apply any time. If you qualify, your coverage can begin immediately, any time of year (www.healthcare.gov/glossary)
Stand-alone dental plan
A type of dental plan offered through the Marketplace that’s not included as part of a health plan (www.healthcare.gov/glossary)
Brand name drug
A drug sold by a drug company under a specific name or trademark and that is protected by a patent (www.healthcare.gov/glossary)
Dependent coverage
Insurance coverage for family members of the policyholder, such as spouses, children, or partners (www.healthcare.gov/glossary)
How many digits does a payer ID usually contain?
5 digits
Modifier 25
used when a procedure is performed on the same day as an E&M visit (“Medical Billing and Coding for Dummies”)
Modifier 59
used to un-bundle a procedure (https://www.aapc.com)
Level-one
level of code used when patient is getting better (“Medical Billing and Coding for Dummies”)
Level-two
level of code used when patient isn’t getting better (“Medical Billing and Coding for Dummies”)
Level-three
level of code used when patient is declining fast (“Medical Billing and Coding for Dummies”)
Inpatient
person who has been officially admitted to the hospital under a physician’s order, until the day before the day of discharge (“Medical Billing and Coding for Dummies”
How long is standard COBRA coverage available for?
18 months (“Medical Billing and Coding for Dummies”)
