20 terms

Chapter 2 - Understanding Managed Care: Insurance Plans

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Assignment Of Benefits
Patient's written authorization giving the insurance company the right to pay the physician directly for billed charges.
Carriers
Parties responsible for issuing insurance policies.
Commercial Health Insurance
Any type of health insurance not paid for by a government agency. Can be based on fee for service or managed care. AKA: Private Health Insurance
Copayment
Amount insured pays at each doctors visit or hospital encounter.
Deductible
Amount insured pays before the insurance company pays.
Enrollee
Individual who takes out an insurance policy in his or her name.
Group Insurance
Policy offered to groups of employees and their dependents covered in a single policy and issued by employer or other group.
Inpatient
A patient who has been admitted to the hospital and is expected to stay 24 hours or more.
Insured
An individual listed as the policyholder under an insurance agreement.
Outpatient
A patient who is treated at a hospital or other medical facility during a stay of less than 24 hours.
Point-Of-Service
A type of managed healthcare plan that allows the member to choose between an HMO, PPO or indemnity plan at the time of service.
Policyholder
The person who owns an insurance policy
Preauthorizations
Allow a patient to receive treatment using their benefits. Some insurance companies require this prior to admission for a hospital stay or outpatient surgery.
Preexisting Condition
An illness or disorder of a beneficiary that existed before the effective date of insurance coverage.
Premiums
Amount you pay to purchase different types of insurance. Often deducted from an employee's paycheck.
Providers
Individuals of facilities providing medical care.
Referral
Transfer of patient care from one physician to another.
Special Risk Insurance
Type of insurance where a person can obtain protection against a certain type of accident or illness such as a plane crash or cancer
Subscribers
Policyholders; members of an insurance benefit plan
Utilization
A review process that compares requests for medical services to treatment guidelines that are deemed appropriate for such services and includes the preparation of a recommendation based on that comparison.