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Medical Insurance Chapter 1 Vocab
Medical Insurance Chapter 1 Vocab
Terms in this set (50)
monies owed to a medical practice and third-party payers.
the process followed by health plans to examine claims.
the amount of money a health plan pays for services covered in an insurance policy
payment method in which a prepayment covers the provider's services to a plan member for a specified period of time.
the portion of charges that an insured person must pay for health care services after payment of deductible amount; usually stated as a percentage.
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.
an amount that a health plan requires a beneficiary to pay at the time of service for each health care encounter.
medical procedures and treatments that are included as benefits under an insured health plan.
standard of conduct based on moral principles
standards of professional behaviors.
A service specified in a medical insurance contract as not covered.
method of charging under which a provider's payment is based on each service performed.
health care claim
an electronic transaction or a paper document filed with a health plan to receive benefits
health maintenance organization (HMO)
A manged health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan; uually members must receive medical services only from the plan's providers.
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 governmental and nongovernmental plans.
type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits.
a system that combines the financing and the delivery of appropriate, cost-effective health care services to its members.
managed care organization (MCO)
organization offering some type of managed health care plan
medical office staff with specialized training who handle the diagnostic and procedural coding of medical records
a financial plan that covers the cost of hospital and medical care.
medical insurance specialist
medical office administrative staff who handles billing, checks insurance, and processes payments.
payment criterion of payers that requires medical treatments to be 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 by an appropriate level, not to be elective, not to be experimental, and not to 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 procedure 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 card.
a provider that does not have a participation agreement with a plan.
expenses the insured must pay before benefits begin.
contractual agreement by a provider to provide medical services to a payer's policyholders.
a record of all charges and payments made on a particular patients account
healthplan or program
per member per month (PMPM)
periodic capitated prospective payment to a provider that covers only services listed on the schedule of benefits.
point-of-service (POS) option
In HMO's 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 and 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 feature.
prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered
An illness or disorder of a beneficiary that existed before the effective date of insurance coverage.
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 receives services from non-network providers for a higher charge.
money the insured pays to a health plan for a health care policy.
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 know as a gatekeeper.
a 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 is includes acting with honor and integrity, being motivated to do one's best, and maintaining a professional image.
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. 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.
schedule of benefits
list of medical expenses that a health plan covers.
self-funded health plan
a company creates its own insurance plan for its employees, rather than using a carrier; the plan assumes payment risk, contracts with physcians, and pays for claims from its funds.
private or government organization that insures or pays for health care on behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party.
an amount that an insured person must pay , usually on an annual basis for health care services before a a health plan's payment begin.
a number signed to a diagnosis in the International Classification of Diseases.
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