58 terms

Chapter 3 Basic of Health Insurance

noncancelable policy
insurer cannot increase premium rates and must renew the policy until the insured reaches the age specified in the contract
independent or individual practice association
type of HMO in which a program administrator contracts with a number of physicians who agree to provide treatment to subscribers in their own offices. Physicians receive reimbursement on a capitation for fee-for-service basis; also referred as a medical capitatin plan
health maintenance organization
A comprehensive health care financing and delivery organization that provides a wide range of health care services with an emphasis on preventive medicine to enrollees within a geographic area through a panel of providers. Primary Care physician "gatekeepers" are usually reimbursed via capitation.
person covered under an insurance program's contract, including (1) subscriber or contract holder who is the person named on the membership identification card and (2) in the case of (a) two-person coverage, (b) one adult-one child coverage, or (c) family coverage, the eligible family dependents enrolled under the subsriber's contract.
preferred provider organization
a type of health benefit program in which enrollees receive the highest level of benefits when they obtain services from a physician, hospital, or other health care provider designated by their program as a "perferred provider."
accounts receivable management
The organization and administration of coding and billing in a medical practice
Person applying for insurance coverage
blanket contract
Comprehensive group insurance coverage through plans sponsored by professional associations for their members
System of payment used by managed care plans in which physicians and hospitals are paid a fixed, per capita amount for each patient enrolled over a stated period regardless of the type and number of services provided; reimbursement to the hospital on a per-member/per-month basis to cover costs for the members of the plan.
The Civilian Health and Medical Program of the Department of Veterens Affairs (CHAMPA)
A program for veterans with total, permanent, service-connected disabilities or surviving spouses and dependents of veterans who died of service-connected disabilities.
A bill sent to an insurance carrier requesting payment for services rendered; also known as encounter form.
Portion of covered charges the insured must pay beyond any applicable deductible. It is a specified percentage of each fee for a covered service the patient must pay to provider (for Medicare, after application of the yearly cash deductible, the portion of the reasonable charges (20%) for which the beneficiary is responsible).
competitive medical plan
(CMP), A state licensed health plan similar to a health maintenance organization (HMO) that delivers comprehensive, coordinated services to voluntarily enrolled members on a prepaid capitated basis, CMP status may be granted by the federal government for the enrollment of Medicare beneficiaries into managed cared plans, without having to qualify as an HMO
conditionally renewable
An insurance policy renewal provision that grants the insurer a limited right to refuse to renew a health insurance policy at the end of a premium payment period
a legally enforceable agreement when relating to an insurance policy; for workers' compensation cases, an agreement involving two or more parties in which each is obligated to the other to fulfill promises made.
coordination of benefits
two insurance carriers working together and coordinating the payment of their benefits so that there is no duplication of benefits paid between the primary and secondary insurance carriers.
daily business record of charges and payments
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
disability income insurance
A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease-not as a result of a work-related accident or condition
electronic signature
Electronic approval of a document that has the same legal status as a written signature.
Qualifying factors that must be met before a patient receives benefits under a specified insurance plan, government program, or managed care plan.
emancipated minor
Person younger than 18 years of age who lives independently, is totally self-supporting, is married or divorced, is a parent even if not married, or is in the military and possesses decision-making rights.
encounter form
a form that can be customized to medical specialties and preprinted with common diagnosis and prodeures for that particular specialty.
provisions written into the insurance contract denying coverage or limiting the space of coverage
exclusive provider organization
EPO, A type of managed health care plan that combines features of HMOs and PPOs. it is referred to as "exclusinve" because it is offered to large employers who agree not to contract with any other plan. EPOs are regulated under state health insurance laws.
expressed contract
a written or oral agreement in which all terms are explicitly stated
financial accounting record
An individual record indicating charges, payments, adjustments, and balances owed for services rendered, also known as a ledger
foundation of medical care
an organization of physicians sponsered by a state or local medical association concerned with the development and delivery of medical services and the cost of health care.
guaranteed renewable
A clause in an insurance policy that means the insurance company must renew the policy as long as premium payments are made. However, the premium may be increased when it is renewed. These policies may have age limits of 60, 65, or 70 years or may be renewable for life.
An individual who promises to pay the medical bill by signing a form agreeing to pay or who accepts treatment constitutes an expressed promise.
health insurance
a written agreement between two parties, called a policy, whereby one entity promises to pay a specific sum of money to a second entity if certain specified undesirable events occur
high risk
A high chance of loss
implied contract
the unwritten contract between a healthcare provider and a patient that has all the components of a legal contract and is just as binding
the people protected by the policy
major medical
Health insurance policy designed to offset heavy medical expenses resulting from catastrophic or prolonged illness or injury.
maternal and child health program (MCHP)
a state service organization to assist children younger than 21 year of age who have conditions leading to health problems
Medicaid (MCD)
a federally aided, state operated and administered program that provides medical benefits for certain low-income persons in need of health and medical care.
a transfer, after an event insured against, or an individual's legal right to collect an amount payable under an insurance contract.
noncancelable policy
insurer cannot increase premium rates and must renew the policy until the insured reaches the age specified in the contract
nonparticipating provider (nonpar)
a provider who does not have a signed agreement with Medicare and has an option about assignment.
optionally renewable
An insurance policy renewal provision in which the insurer has the right to refuse to renew the policy on a date and may add coverage limitations or increase premium rates
participating provider (par)
one who accepts TRICARE assignment.
patient registration form
A questionnaire designed to collect demographic data and essential facts about medical insurance coverage for each patient seen for professional services
personal insurance
An insurance plan issued to an individual (or his or her dependent): also know as individual contract
point-of-service (POS) plan
managed care plan in which members are given a choice as to how to receive services.
To record or transfer financial entries, debit or crdit, to an account (e.g., daysheet, financial account record [ledger], bank deposit slip, check register, or journal.
A requirement of some health insurance plans to obtain permission for a service or procedure before it is done to see whether the insurance program agrees it is medically necessary
Determination of the potential dollar amount the insurance company will pay for a particular treatment.
preexisting conditions
certain illnesses or injuries that exist before an effective date of the insurance policy are not covered
The periodic amount of money the insured pays to a health plan for insurance coverage
running balance
An amount owed on a credit transaction; also known as outstanding or unpaid balance.
state disability insurance
insurance that covers off-the-job injury or sickness and is paid for by deductions from a person's paycheck.
One who belongs to a group insurance plan.
a three-option managed health care program offered to spouses and dependents of service personnel with uniform benefits and fees implemented nationwide by the federal government
unemployment compensation disability
(UCD) Insurance that covers off-the-job injury or sickness and is paid for by deductions from a person's payness and is paid for by dedcutions from a person's paycheck. This program is administered by a state agency and is sometimes also known as State Disability nsurance (SDI) or temporary disabilty insurance (TDI)
Veterans Affairs (VA) outpatient clinic
A clinic where medical and dental services are rendered to veterans who have service-related disabilities.
workers' compensation insurance
provides insurance for employees who suffer a job-related illness of injury
benefits paid to an insured while disabled (reimbursement)