a financial plan that covers the cost of hospital and medical care due to illness or injury.
a person who buys an insurance plan; the insured
plan, program, or organization that provides health benefits
health plan payment for covered services
health plan or program
A private or governmental organization that insures or pays for health care on the behalf of beneficiaries
schedule of benefits
list of medical expenses that a health plan covers.
Medical necessity of services/procedures must be justified by patient's symptoms and diagnosis - it is a criterion used by insurers in their decision to limit or deny payment.
A person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business.
medical procedures and treatments that are included as benefits under an insured health plan.
preventive medical services
care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests
non covered services
not medicaly necesaries, investigational procedures, cosmetic procedures,
A service specified in a medical insurance contract as not covered.
An illness or disorder of a beneficiary that existed before the effective date of insurance coverage.
health plan that offers protection from loss.
health care claim
an electronic transaction or a paper document filed with a health plan to receive benefits
amount paid for insurance coverage
Specified amount of money that the insured must pay for covered medical expenses before the insurance policy begins to pay; usually annual amount per individual or family
Portion of covered charges the insured must pay beyond any applicable deductible.
Expenses the insured must pay before benefits begin.
Method of charging under which a provider's payment is based on each service performed.
a system for combining the financing and delivery of health care services
managed care organization -MCO
organization offering some type of managed health care plan
contracual agreement to provide medical services to a payer's policyholder
health maintenance organization -HMO
a manage health care system in which providers agree to offer health care to the organization's members for fixed payment
A prepayment covers the provider's services to a plan member for a specified period of time.
per member per month-PMPM
per member per month (PMPM) Refers to the fees paid on a capitation plan. The rate is based on a list with a number of members sent to the provider at the beginning of the month. The provider is paid up front for medical services rendered whether the patients are treated or not.
Providers and suppliers who participate in a particular managed care organization or health plan.
a provider that does not have a participation agreement with a plan.
prior authorization from a payer for services to be provided
a small fixed fee paid by the patient at the time of an office visit--copay
primary care physician
PCP,, Physician who oversees care of patients in a managed health care plan.
Transfer of patient care from one physician to another.
can visit any specialist in the network without a referral.
point-of-service (POS) plan
A type of HMO that allows members to seek care from non-HMO physicians, but at higher premiums, co-payments, and deductibles than for traditional HMO's
preferred provider organization
managed care network of health care providers who agree to perform services for plan members at discounted fees.
consumer-driven health plan
Type of medical insurance that combines a high deductible health plan with a medical savings plan which covers some out of pocket expenses.
self-funded health plan
organization pays for health insurance directly and sets up a fund from which to pay--also called self-insured
medical insurance specialist
the person in a medical office who handles patients' health care claims
Patient Protection and Afforable Care Act-PPACA
health system reform legislation that introduced significant benefits for patients
a person who analyzes and codes patient diagnoses, procedures, and symptoms
the number assigned to a diagnosis
A code that identifies a medical service
A record of all charges and payments made on a particular patient's account.
actions that satisfy offical requirements
money owed to a business
The process followed by health plans to examine claims and determine benefits.
practice management program-PMP
business software designed to organize and store a medical practice's financial information; often includes scheduling, billing and electronic medical records feature.
how a person behaves when he or she is on the job.
moral principles or values
standards for professional behavior
recognition of having met certain standards
4 conditions must be met before insurance company will pay
1)charges must be necessary
2)payment of premium
3)deductible must be met
4)coinsurance claim must be taken into account