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Mod 150 Unit 2
Mod 150/Unit 2
Terms in this set (43)
assignment of benefits
patient's written authorization giving the insurance company the right to pay the physician directly for billed charges
used by insurance claims administrators to determine which parents plan will pay for the medical bills of a dependent child when the child is covered by plans of both parents
predetermined amount paid to provider every month regardless of the number of times the patient is seen within the month
written and documented request for reimbursement of an eligible expense under an insurance plan.
health insurance claim form that has been completed correctly without any errors or omissions
independent entity that reviews claims, requests clarification from the provider, and "cleans" claims, ensuring accurate information is documented, then submits claims to insurance companies in proper format
most common health insurance claim form used to file claims for physicians services
cost of claims shared by insurance company and insured after deductible
Coordination of Benefits
procedures to prevent duplication of payment by more than 1 insurance carrier
predetermined amounts of money the patient must pay for medical services at every visit, as determined by the insurance company.
patient claIM THAT IS ELIGIBLE FOR BOTH MEDICARE AND MEDICAID; ALSO KNOWN AS MEDI/MEDI
amount of eligible charges each patient must pay each calendar year before the insurance plan begins to pay benefits
occurs when procedures or services are not covered by the patient's insurance policy or when the patient has not met his or her deductible
a health insurance claim form that is incorrectly because it has missing data or errors
social insurance for the disabled
a health care claim that is transmitted electronically; also known as an electronic media claim (EMC)
Exclusive Provider Organizations
combination of PPO and HMO concepts that allows the patient to select from a defined panel of providers
schedule of amount paid by a specific insurance company for each procedure or service subject to the managed care contract
regulated by the federal or state government., EX: medicare, medical, tricare/champva, workers compensation
Health Maintenance Organizations (HMOs)
managed care plan in which a range of health care services provided by a limited group of providers (such as specified physicians or hospitals)bare made available to plan members for a predetermined fee.
health insurance claim form that has been completed but contains some type of incorrect information.
Health insurance policy designed to offset heavy medical expenses resulting from catastrophic or prolonged illness or injury.
health care for the needy
a U.S. Government insurance program for which persons aged 65 and over and others with special conditions are eligible.
Medicare Part A
The part of the Medicare program that pays for hospitalization, care in a skilled nursing facility, home health care, and hospice care.
Medicare Part B
The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.
a physician to whom the patient is expected to pay charges before submitting the claim to the insurance company, which pays the patient directly
One who has a contractual agreement with an insurance plan to render care to eligible beneficiaries and then bill the insurance carrier directly
set of fees for services established by a health care provider and paid for by the patient
insurance plan in which a patient may choose an HMO or a non-HMO provider but must pay a deductible for using a non-HMO proivider
requirement to obtain prior approval for surgery and other procedures from the insurance carrier in order to receive reimbursement.
Preferred Provider Organizations (PPO)
an insurance agreement that requires the patient to use a provider under contract to the insurance company, which reimburses the provider at a discounted rate.
amount paid for insurance
group of physicians or other health care providers who have a contractual agreement to provide services to subscribers on a negotiated fee-for-service or captivated basis; also known as "Managed Care Plan".
Primary Care Provider (PCP)
gatekeeper provider who refers patients to other providers for services he or she cannot perform
medical insurance coverage provided through the patient's employer.
occurs when a patient chooses to see an out-of-network provider without authorization
A managed care plan administered by the department of defense
Insurance claim or flat file used to bill institutional services, such as services performed in hospitals.
usual, customary. and reasonable
the initial period of time that an injured person must wait before they are eligible to receive the financial benefits
A form of insurance paid by the employer providing cash benefits to workers injured or disabled in the course of employment.
to agree to forfeit the amount the insurance company does not authorize
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