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Medical Insurance Chapter one
Medical Insurance Chapter one
Terms in this set (53)
accounts receivable (A/R)
Monies owed to a medical practice by its patients and third-party payers.
The process followed by health plans to examine claims and determine benefits.
The amount of money a health plan pays for services covered in an insurance policy.
Term for a Blue Cross and Blue Shield medical insurance policy.
Actions that satisfy official guidelines and requirements.
consumer-driven health plan (CDHP)
Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses.
Medical procedures and treatments that are included as benefits under an insured's health plan.
The number assigned to a diagnosis in the International Classification of Diseases.
Standards of conduct based on moral principles.
Standards of professional behavior.
A service specified in a medical insurance contract as not covered.
health care claim
An electronic transaction or a paper document filed with a health plan to receive benefits.
Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers, health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other government and nongovernment plans.
Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits.
managed care organization (MCO)
Organization offering some type of managed health care plan.
System that combines the financing and the delivery of appropriate, cost-effective health care services to its members.
Medical office staff member with specialized training who handles the diagnostic and procedural coding of medical records.
medical insurance specialist
Medical office administrative staff member who handles billing, checks insurance, and processes payments.
Financial plan that covers the cost of hospital and medical care.
Payment criterion of payers that requires medical treatments to be clinically appropriate and provided in accordance with generally accepted standards of medical practice. To be medically necessary, the reported procedure or service must match the diagnosis, be provided at the appropriate level, not be elective, not be experimental, and not be performed for the convenience of the patient or the patient's family.
A group of providers having participation agreements with a health plan. Using in-network providers is less expensive for the plan's enrollees.
Medical procedures that are not included in a plan's benefits.
Type of health maintenance organization in which a member can visit any specialist in the plan's network without a referral.
A provider who does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan's enrollees.
Expenses the insured must pay before benefits begin.
Contractual agreement by a provider to provide medical services to a payer's policyholders.
Record of all charges, payments, and adjustments made on a particular patient's account.
Patient Protection and Affordable Care Act (PPACA)
Health system reform legislation signed in 2010 that introduced a number of significant benefits for patients.
Health plan or program.
per member per month (PMPM)
Periodic capitated prospective payment to a provider who covers only services listed on the schedule of benefits.
point-of-service (POS) plan
In HMOs, plan that permits patients to receive medical services from non-network providers; this choice requires a larger patient payment than visits with network providers.
Person who buys an insurance plan; the insured, subscriber, or guarantor.
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 features.
Prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered.
Illness or disorder of a beneficiary that existed before the effective date of insurance coverage.
preventive medical services
Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests.
primary care physician (PCP)
A physician in a health maintenance organization who directs all aspects of a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper.
Code that identifies medical treatment or diagnostic services.
For a medical insurance specialist, the quality of always acting for the good of the public and the medical practice being served. This includes acting with honor and integrity, being motivated to do one's best, and maintaining a professional image.
Person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business. A provider may be a professional member of the health care team, such as a physician, or a facility, such as a hospital or skilled nursing home.
Transfer of patient care from one physician to another.
self-funded (self-insured) health plan
An organization that assumes the risks of paying for health insurance directly and sets up a fund from which to pay.
Private or government organization that insures or pays for health care on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party.
health maintenance organization (HMO)
A managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan; usually members must receive medical services only from the plan's providers.
Payment method in which a prepayment covers the provider's services to a plan member for a specified period of time.
schedule of benefits
List of the medical expenses that a health plan covers.
Method of charging under which a provider's payment is based on each service performed.
The portion of charges that an insured person must pay for health care services after payment of the deductible amount; usually stated as a percentage.
An amount that an insured person must pay, usually on an annual basis, for health care services before a health plan's payment begins.
An amount that a health plan requires a beneficiary to pay at the time of service for each health care encounter.
Money the insured pays to a health plan for a health care policy.
preferred provider organization (PPO)
Managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.
Protection from loss.
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