Chapter 14 Health Insurance Terms – Flashcards

Unlock all answers in this set

Unlock answers
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.
Get an explanation on any task
Get unstuck with the help of our AI assistant in seconds
New