| Term | Definition |
|---|
| policyholder | individual who has contracted with a health plan for coverage |
| health plan | plan, program, or organization that provides health benefits |
| premium | payment made to a health plan by a policyholder for coverage |
| payer | private or government organization that insures or pays for health care |
| fee-for-service | insurance plan in which policyholders are reimbursed for health care costs |
| coinsurance | under an insurance plan, the portion or % of the charges that the patient is responsible for paying |
| managed care | type of insurance in which the carrier is responsible for the financing and delivery of health care |
| preferred provider organization | network of health care providers who agree to provide services to plan members at a discounted fee |
| health maintenance organization | type of managed care system in which providers are paid fixed rates at regular intervals |
| co-payment | small fixed fee paid for by the patient at the time of an office visit |
| consumer driven health plan | type of managed care in which a high-deductible/low-premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses, up to the deductible limit |
| patient information form | document that contains personal, employment, and medical insurance information about a patient |
| capitation | fixed amount that is paid to a provider in advance to provide medically necessary services to patients |
| encounter form | form listing producures relevant to the specialty of a medical office, used to record the procedure |
| diagnosis | physician's opinion of the nature of the patient's illness or injury |
| procedure | medical treatment provided by a physician or other health care provider |
| coding | process of assigning standardizes codes to diagnoses and procedures |
| diagnosis code | value that stands for a patient's illness, signs, or symptoms |
| procedure code | number that represents medical procedures performed by a provider |
| modifier | two-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service |
| practice managemant program | software program that automates many of the administrative and financial tasks required to run a medical practice |
| medical coder | person who analyzes and codes patient diagnoses, procedures, and symptoms |
| medical necessity | treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and provided in accordance with generally accepted standards of medical practice |
| adjudication | series of steps that determine whether a claim should be paid |
| remittance advice | electronic document from a health plan that lists the amount of a benefit and explains how it was determined |
| explanation of benefits | paper document from a health plan that lists the amount of a benefit and explains how it was determined |
| statement | list of all services performed for a patient, along with the charges for each service |
| billing cycle | regular schedule of sending statements to patients |
| accounting cycle | flow of financial transactions in a business |
| accounts recievable | term used to describe money coming in to a business |
Combine with other sets
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