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CH 17 Terms from Lindh Medical Insurance

insurance abuse

improper or excessive use, overcharging for services; inconsistent with acceptable business practices that could result in an unauthorized payment

Insurance adjustment

the dollar adjusted off the patient's account reflecting the difference between the fee for services billed and the allowed amount determined by the insurance company

assignment of benefits

Authorization by policyholder that allows a health plan to pay benefits directly to a provider.


the recipient of funds or other benefits

benefit period

Period of time for which payments for Medicare inpatient hospital benefits are available. A benefit period begins the first day an enrollee is given inpatient hospital care (nursing care or rehabilitation services) by qualified provider and ends when the enrollee has not been inpatient for 60 consecutive days. For disability insurance, it is the maximum amount of time that benefits will be paid to the injured or ill person for a disability.


A common method of reimbursement used primarily by health maintenance organizations in which the provider or medical facility is paid a fixed, per capita amount for each individual enrolled in the plan, regardless of how many or few services the patient uses.

Centers for Medicare and Medicaid Services (CMS)

federal government agency that administers medicare/medicaid, federal agency within the Department of Health and Human Services (HHS) that runs Medicare, Medicaid, Clinical Laboratories (under the CLIA program) and other governmental health programs. Formerly Health Care Financing Administration (HCFA)


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

coordination of benefits (COB)

procedures used by insurers to avoid duplication of payment on claims when the patient has more than one policy. One insurance becomes the primary payer, and no more than 100% of the costs are covered


a small fixed fee paid by the patient at the time of an office visit


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

Defense Enrollment Eligible Reporting (DEERS)

a system operated by the department of defense and used by Tricare contractors to determine and confirm the eligibilty of beneficiaries

insurance exclusion

specific disease or condition listed on an insurance policy for which the policy will not pay

Exclusive Provider Organization (EPO)

managed care plan that provides benefits to subscribers if they receive services from network providers (doctors) not required to select PCP & don't need a referral to see a specialist

Explanation of Benefits (EOB)

A document from a payer sent to a patient that shows how the amount of a benefit was determined.

Medicare donut hole

coverage gap within the Medicare Part D prescription drug program. After the pt has used the initial $2400 coverage of drubs they must pay for the next $3,051. After that coverage takes over again.

fiscal intermediary

an organization under contract to the government that handles claims under medicare

insurance fraud

Any fraud that involves an insurance company, whether committed by consumers, insurance company employees, producers, health care providers, or anyone else connected with and insurance transaction.

Health Maintenance Organization (HMO)

A managed health care system in which providers agree to offer health care to the organization's members for fixed payments

Integrated Delivery System (IDS)

a system incorporating acute care services, home health care, extended and skilled care facilities, and outpatient services.

Managed Care Organization (MCO)

a type of medical plan that pays for and manages the medical care a patient receives.

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.

Medicare Part C

Managed Healthcare plans that offer regular Part A and Part B Medicare coverage and additional coverage for certain other services are called:

Medicare Part D

prescription drug reimbursement plans offered to Medicare beneficiaries

Medigap Policy

supplemental plans designed by the federal government but sold by private commercial insurance companies to cover the cost of Medicare deductibles, copayments, & coinsurance, which are considered "gaps" in Medicare coverage

pre-existing condition

a medical condition for which a new insured has been treated recently, which may be excluded from coverage for a specified time

Birthday Rule

The guidelines that determines which of two married parents with medical coverage from different employers has the primary insurance for a child; the parent whose day of birth is earlier in the calendar year is considered primary

remittance advice

an electronic or paper-based report of payment sent by the payer to the provider


prior approval of insurance coverage and necessity of procedure

insurance claim

A formal request to the insurance company for reimbursement for a covered loss.


A universal claim form developed by CMS and used by providers of services to bill professional fees to health carriers.

direct payment

payment for procedures that is made by an insurance company or a patient to a provider

fee for service

Method of charging under which a provider's payment is based on each service performed.

resource based relative value scale

RBRVS, A system that ranks physician services by units and provides a formula to determine a Medicare fee schedule.


The Civilian Health and Medical Program of the Veterans Administration (now known as the Department of Veterans Affairs) which shares health care costs for families of veterans with 100 percent service-connected disability and the surviving spouses and children of veterans who die from service-connected disabilities.


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

usual customary reasonable fees

Usual: The usual fee for a given service is the fee that the physician most frequently charges for the service. Customary: A range of the usual fees charged for the same service by physicians with similar background and training. Reasonable: Services or procedures that are particularly difficult or complicated, requiring extraordinary time and effort.Abbreviated: UCR


diagnostic related group

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