question

Allowed amount

answer

The maximum amount an insurer will pay for any give service

question

Assignment of Benefits

answer

The authorization, by signature of the patient, for payment to be made directly by the patient's insurance to the provider for services.

question

Authorization to release medical information

answer

A form that must be signed by the patient before any information may be given to an insurance company or any other third party

question

First party

answer

The patient`

question

Second Party

answer

The health service provider

question

The third party

answer

The insurance company

question

Beneficiary

answer

Person entitled to benefits of an insurance policy. This term is most widely used by Medicare

question

Capitation

answer

The health care provider is paid a fixed amount per member per month for each patient who is a member of a particular insurance organization regardless of whether services were provided

question

Carrier

answer

The Third Party. Term used to refer to insurance companies that reimburse for health care services.

question

Civilian Health and Medical Program of the Veterans' Administration (CHAMPVA)

answer

Established for spouses and dependent children of veterans who have total, permanent, service-connected disabilities

question

CMS-1500 Form

answer

The standard claim form designed by the Centers for Medicare and Medicaid Services to submit provider services for third-party payment

question

Coinsurance

answer

The percentage owed by the patient for services rendered after a deductible has been met and a copayment has been paid

question

Coordination of Benefits (COB)

answer

Procedures insurers use to avoid duplication of payment on claims when the patient has more than one policy. One insurer becomes the primary payer and no more than 100 % of the costs are covered

question

Copayment

answer

A specified amount the insured must pay toward the charge for professional services rendered at the time of service

question

Deductible

answer

A predetermined amount the insured must pay each year before the insurance company will pay for an accident or illness

question

Diagnosis-related group (DRG)

answer

A prospective payment system used by Medicare to classify illnesses according to diagnosis and treatment. DRG's group all charges for hospital inpatient services into a single bundle for payment purposes

question

Effective date

answer

the date when the Insurance policy goes into effect

question

Explanation of Benefits`

answer

A printed description of the benefits provided by the insurer to the beneficiary

question

Fee disclosure

answer

The action of health care providers informing patients of charges before the services are performed.

question

Fee Schedule

answer

A list of predetermined payment amounts for professional services provided to patients

question

Gatekeeper

answer

Term give to primary care providers because they are responsible for coordinating the patient's care to specialists, hospital admissions, ETC

question

Group Insurance

answer

Insurance offered to all employees by an employer

question

Health Maintenance organization (HMO)

answer

Group insurance that entitles members to services provided by participating hospitals, clinics, and providers

question

Individual Insurance

answer

Insurance purchased by an individual or family w no access to group insurance

question

Limiting Charge

answer

The maximum amount a non participating provider can collect for services provided to a Medicare patient

question

Loss-of Income Benefits

answer

Payments made to an insured person to help replace income lost through payment of the services

question

Medicaid

answer

A joint funding program by Federal and State Governments for the medical re of LOW INCOME patients on ublic assistance

question

Medicare

answer

A federal program for providing health care coverage for individuals over the age of 65 or disabled

question

Medicare Fee Schedule

answer

A list of approved professional services Medicare will pay for with the maximum fee if pays for each service

question

Medigap

answer

Private insurance to supplement Medicare benefits for payment of the deductible, copayment and coninsurance

question

Member Provider

answer

A provider who has contracted to participate with an insurance company to be reimbursed for services

question

National Committee for Quality Assurance (NCQA)

answer

A nonproﬁt organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector.

question

Nonparticipating provider

answer

A provider who is not contracted with an insurer and can collect total charges for services provided. Exception: Provider can collect only 115 percent of the Medicare Provider Fee Schedule allowed amount for Medicare beneﬁciaries.

question

Out-of-area

answer

The term used to identify services HMO members receive outside of their speciﬁed geographical area.

question

Participating provider

answer

A provider who has contracted with an insurer and accepts whatever the insurance pays as payment in full.

question

Patient status

answer

Refers to a patient's eligibility for beneﬁts; the basis upon which beneﬁts are being provided (i.e., inpatient, outpatient, ER, ofﬁce etc.)

question

Point-of-service (POS) plan

answer

An open-ended HMO, which delivers health care services using both a managed care network and traditional indemnity coverage. Care sought outside the managed care network results in higher out-of-pocket costs for the member.

question

Precertiﬁcation

answer

Approval obtained before the patient is admitted to the hospital or receives speciﬁed outpatient or in-ofﬁce procedures.

question

Precertification

answer

A condition that existed before the insured's policy was issued.

question

Preferred provider organization (PPO)

answer

A network of providers and hospitals that are joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers and their families for a discounted fee.

question

Premium

answer

Monies paid for an insurance contract.

question

Relative Value Units

answer

Numeric values assigned to payment components of the Resource-Based Relative Value Scale (RBRVS).

question

Resource-based relative value scale (RBRVS)

answer

Fee schedule based on relative value units assigned for resources providers use to provide services for patients: provider work, practice expense, malpractice expense.

question

Service Area

answer

The geographic area served by an insurance carrier.

question

Subscriber

answer

The person who has been insured; an insurance policy holder.

question

Third Party Payer

answer

An insurance carrier who is not the doctor or patient but who intervenes to pay the hospital or medical bills per contract with one of the ﬁrst two parties.

question

TRICARE (Civilian Health and Medical Program of the Uniformed Services, CHAMPUS)

answer

Established to aid dependents of active service personnel, retired service personnel and their dependents, and dependents of service personnel who died on active duty, with a supplement for medical care in military or public health service facilities.

question

Usual, customary, and reasonable (UCR) fee

answer

The amount commonly charged for a particular medical service by providers in a speciﬁc geographical area; amounts are used to develop allowed amounts.

question

Utilization management (review)

answer

A method of controlling health care costs by reviewing services to be provided to members of a plan to determine the appropriateness and medical necessity of the care prior to the delivery of the care.

question

Waiver

answer

A document outlining services that will not be covered by a patient's insurance carrier and the cost associated with those services. Patient signature indicates that he or she understands that these services will not be covered and that he or she agrees to pay for the service out of pocket.

question

Worker's Compensation

answer

Government program that provides insurance coverage for those who are injured on the job or who have developed work-related disorders, disabilities, or illnesses.

Chapter 14 Health Insurance Terms – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards