Comprehensive Insurance Terminology & Abbreviations List

Created by MzGigi 

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(CRI)
CHAMPUS Reform Initiative

conducted in 1988; resulted in a new health program called TRICARE, which includes three options: TRICARE Prime, TRICARE Extra, and TRICARE Standard.

(CHAMPVA)
Civilian Health and Medical Program of the Department of Veterans Affairs

program that provides health benefits for dependents of veterans rated at 100 percent permanently or totally disabled as a result of service-connected conditions, veterans who died as a result of service-connected conditions and veterans who died on duty with less than 30 days of active service.

(CHAMPUS)
Civilian Health and Medical Program- Uniformed Services

originally designed as a benefit for dependents of personnel serving in the armed forces and uniformed branches of the Public Health Service and the National Oceanic and Atmospheric Administration; now called TRICARE.

CMS-1500 (08-05)

form used to submit Medicare claims; previously called the HCFA-1500

Coinsurance

the percentage the patient pays for covered services after deductible has been met and the copayment has been paid.

(COBRA)
Consolidated Omnibus Budget Reconciliation Act of 1985

allows employees to continue healthcare coverage beyond the benefit termination date.

(DRG)
Diagnosis-related group

prospective payment system that reimburses hospitals for inpatient stays.

(EHR)
Electronic health record

global concept that includes the collection of patient information documented by a number of providers at different facilities regarding one patient.

(EMR)
Electronic medical record

considered part of the electronic health record (EHR), the EMR is created on a computer using a keyboard, a mouse, an optical pen device, a voice recognition system, a scanner, or a touch screen; records are created using vendor software, which assists in provider decision making; numerous vendors offer EMR software, mostly to physician office practices that require practice management solutions.

(FECA)
Federal Employees' Compensation Act

replaced the 1908 workers' compensation legislation; civilian employees of federal government are provided medical care, survivors' benefits, and compensation for lost wages.

Fee schedule

list of predetermined charges for services provided to patients (e.g., a fee is assigned to each CPT code).

(POR)
Problem-orientated record

a systematic method of documentation that consists of four components: database, problem list, initial plan, and progress notes.

Self-insured (self-funded)
employer-sponsored group health plans

allows a large employer to assume the financial risk for providing healthcare benefits to employees; employer does not pay a fixed premium to a health insurance payer, but establishes a trust fund (of employer and employee contributions) out of which claims are paid.

Single-payer plan

centralized healthcare system adopted by some Western nations (e.g., Canada, Great Britain) and funded by taxes. The government pays for each resident's health care, which is considered a basic social service.

(TPAs)
Third-party administrators

company that provides health benefits claims administration and other outsourcing services for self-insured companies; provides administrative services to healthcare plans; specializes in mental health case management; and processes claims, serving as a system of "checks and balances: for labor-management.

Universal health insurance

goal of providing every individual with access to health coverage, regardless of the system implemented to achieve that goal.

(WHO)
World Health Organization

developed the International Classification of Diseases (ICD codes).

claim

a submission to the insurance company for payment or reimbursement for services renderd to a patient

beneficiary

the person who benefits from the policy

out of pocket maximum

the max amount to be paid

lifetime maximum

the maximum amount the insurance company will pay in lifetime

Medical Saving accounts

Individual accounts that may be set up by self-employed individuals and those who work for
small companies. Funds in the accounts are used to pay medical expenses.

Co-insurance

amount paid for medical care after the deductible is met.

co-pay

flat fee paid by the patient in the office to receive medical care

deductible

amount paid by the patient before the insurance plan pays out on any claims.

Disability insurance

benefits paid to a patient in the event of injury or illness deeming them no longer able to work.

exclusions/ limitations

services that are not covered by a plan

fee-for-service insurance

traditional (indemnity) health insurance where you and your plan each pay a portion of your health expenses, usually after you meet a yearly deductible

flexible spending arrangements (FSA)

employees use pre-tax dollars to set up these accounts and draw down on them to pay qualified medical expenses during the year; unused amounts are forteited

Formulary

an insurance company's list of covered drugs

Group Insurance

Master health plan contract offered to a group of like individuals (employer, association, union, etc.) All having the same coverage.

(HMO)
Health Maintenance Organization

form of managed care in which you receive all of your care from participating providers

health reimbursement arrangement

an account established by an employer to pay an employee's medical expenses; only the employer can contribute to the account

(HSA)
Health Savings Account

an account established by an employer or an individual to save money toward medical expenses on a tax-free basis; remaining balance will "roll over"

high-deductivel health plan

provides comprehensive coverage for high-cost medical events; features high deductibles and a limit on annual out-of-pocket expenses

high-risk pool

a state-operated program that offers coverage for individuals who cannot get health insurance from another source due to serious illness

indemnity insurance

traditional, fee-for-service health insurance that does not limit where a covered individual can get care

individual health insurance

coverage purchased independently, usually directly from an insurance company, e.g. self employed

long-term care insurance

coverage that pays for all or part of the cost of home health care services or care in a nursing home or assisted living facility

managed care

an organized way of getting health care services and paying for care; feature a network of physicians, hospitals, and other providers who participate in the plan

medicaid

a federal program administered by the states to provide health care for certain poor and low-income individuals and families; eligibility varies by state
MEDICALLY NEEDY, recipients of AFDC/ SSI benefits

medicare

a federal insurance program that provides health care coverage to individuals 65 and older, disabled or Blind, permanent kidney failure, or who have had a kidney transplant

network

a group of physicians, hospitals, and other providers who participate or contracted in a managed care plan

open enrollment

a set time of year when y ou can enroll in health insurance or change from one plan to another without benefit of a qualifying event

point-of-service plan

form of managed care plan in which primary care physicians coordinate patient care but there is more flexibility in choosing doctors and hospitals than in an HMO

preferred provider organization (PPO)

form of managed care in which you have more flexibility in choosing physicians and other providers than in an HMO

Premium

amount you pay to belong to a health plan

primary care physician (PCP)

usually a family practice doctor, internist, ob-gyn, or pediatrician; s/he is your first point of contact with the health care system

usual,reasonable and customary (UCR)

the prevailing cost of a medial service in a given geographic area, established by the insurance company

claim

a submission to the insurance company for payment or reimbursement for services renderd to a patient

beneficiary

the person who benefits from the policy

out of pocket maximum

the max amount to be paid

lifetime maximum

the maximum amount the insurance company will pay in lifetime

Medical Saving accounts

Individual accounts that may be set up by self-employed individuals and those who work for
small companies. Funds in the accounts are used to pay medical expenses.

Coinsurance

amount paid for medical care after the deductible is met.

copay

flat fee paid by the patient in the office to receive medical care

deductible

amount paid by the patient before the insurance plan pays out on any claims.

Disability insurance

benefits paid to a patient in the event of injury or illness deeming them no longer able to work.

exclusions/ limitations

services that are not covered by a plan

fee-for-service insurance

traditional (indemnity) health insurance where you and your plan each pay a portion of your health expenses, usually after you meet a yearly deductible

flexible spending arrangements (FSA)

employees use pre-tax dollars to set up these accounts and draw down on them to pay qualified medical expenses during the year; unused amounts are forteited

Formulary

an insurance company's list of covered drugs

Group Insurance

Master health plan contract offered to a group of like individuals (employer, association, union, etc.) All having the same coverage.

Health Maintenance Organization (HMO)

form of managed care in which you receive all of your care from participating providers

health reimbursement arrangement

an account established by an employer to pay an employee's medical expenses; only the employer can contribute to the account

Health Savings Account (HSA)

an account established by an employer or an individual to save money toward medical expenses on a tax-free basis; remaining balance will "roll over"

high-deductivel health plan

provides comprehensive coverage for high-cost medical events; features high deductibles and a limit on annual out-of-pocket expenses

high-risk pool

a state-operated program that offers coverage for individuals who cannot get health insurance from another source due to serious illness

indemnity insurance

traditional, fee-for-service health insurance that does not limit where a covered individual can get care

individual health insurance

coverage purchased independently, usually directly from an insurance company, e.g. self employed

long-term care insurance

coverage that pays for all or part of the cost of home health care services or care in a nursing home or assisted living facility

managed care

an organized way of getting health care services and paying for care; feature a network of physicians, hospitals, and other providers who participate in the plan

medicaid

a federal program administered by the states to provide health care for certain poor and low-income individuals and families; eligibility varies by state
MEDICALLY NEEDY, recipients of AFDC/ SSI benefits

medicare

a federal insurance program that provides health care coverage to individuals 65 and older, disabled or Blind, permanent kidney failure, or who have had a kidney transplant

network

a group of physicians, hospitals, and other providers who participate or contracted in a managed care plan

open enrollment

a set time of year when y ou can enroll in health insurance or change from one plan to another without benefit of a qualifying event

point-of-service plan

form of managed care plan in which primary care physicians coordinate patient care but there is more flexibility in choosing doctors and hospitals than in an HMO

preferred provider organization (PPO)

form of managed care in which you have more flexibility in choosing physicians and other providers than in an HMO

Premium

amount you pay to belong to a health plan

primary care physician (PCP)

usually a family practice doctor, internist, ob-gyn, or pediatrician; s/he is your first point of contact with the health care system

usual,reasonable and customary (UCR)

the prevailing cost of a medial service in a given geographic area, established by the insurance company

AAPC

American Academy of Professional Coders

AHIMA

American Health Information Management Association

AMBA

American Medical Billing Association

Bonding Insurance

An insurance agreement that guarantees repayment for financial losses resulting from an employee's act or failure to act. It protects the financial operations of the employer.

CMS

Centers for Medicare and Medicaid Services

Coding

The process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim. Two systems used are ICD-9CM and HCPCS.

CPT

Current Procedural Terminology

Electronic Claims Processing

Send data in a standardized machine-readable format to an insurance company via disk, telephone cable or modem.

EDI

Electronic Data Interchange - The mutual exchange of data between the provider and the insurance company, and is often used in clearinghouses.

embezzle

steal

errors and omissions insurance

Provides protection from claims resulting in errors and omissions associated with professional services provided to clients as expected of a person in the contractor's profession.

ethics

The principles of right or good conduct, and rules that govern the conduct of members of a profession.

EOB

Explanation of benefits - A report that details the results of a claim.

HCPCS

Healthcare Common Procedure Coding System

Health Care Provider

A physician or other health care practioner ex. physician's assistant, RN, Nurse Practitioner

Health Information Technician

Manage patient health information and medical records, administer computer information systems, and code diagnoses and procedures for health care services provided to patients.

Health Insurance Claim

documentation submitted to an insurance plan requesting reimbursement for health care services provided.

Health Insurance Specialist

Review health-related claims to determine the medical necessity for procedures or services performed before payment (reimbursement) is made to the provider.

Hold Harmless Clause

Patient is not responsible for paying what the insurance plan denies in the contract, the health care provider cannot collect the fees from the patient.

Independent Contractor

A person who performs services for another under an express or implied agreement and who is not subject to the others' control, or right to control, of the manner and means of performing the services.

ICD-9-CM

International Classification of Disease - 9th Revision, Clinical Modification

liability insurance

Protects business assets and covers the cost of lawsuits resulting from bodily injury (e.g., customer slips on wet floor), personal injury (e.g. slander or libel), and false advertising.

medical malpractice insurance

A type of liability insurance, which covers physicians and other health care professionals for liability as to claims arising from patient treatment.

medical necessity

Linking every procedure or service code reported on the claim to a condition code that justifies the necessity for performing that procedure or service.

national codes (level II codes)

Commonly referred to as HCPCS level II codes, which are published by CMS and include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT.

NEBA

National Electronic Billers Alliance

preauthorization

Prior approval for treatment of specialists and post-treatment reports.

professional liability insurance

Provides protection from claims resulting from errors and omissions associated with professional services provided to clients as expected of a person in the contractor's profession.

property insurance

Protects business contents against fire, theft, and other risks.

reimbursement specialist

Review health-related claims to determine the medical necessity for procedures or services performed before payment (reimbursement) is made to the provider.

remittance advice (RA)

notice sent by the Medicare/ that consists of payment information about a claim.

Respondeat Superior

Means that the employer is liable for the actions and omissions of employees as performed and committed within the scope of their employment.

scope of practice

Defines the profession, delineates qualifications and responsibilities, and clarifies supervision requirements.

workers' compensation insurance

Protection mandated by state law that covers employees and their dependents against injury and death occurring during the course of employment.

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