25 terms

Mod h unit 1 theory

What is IPA definition and what does it stand for?
A type of HMO whereby services are provided by outpatient networks composed of individuals health care providers who supply all necessary patient care is a(n)
individual practice association
What category does the four basic types of health insurance fall into?
Indemnity/managed care
What is lifetime insurance cap?
Many FFS policies set a limit for what they will reimburse their members for any charges incurred, whihc is referred to as a(n)
what is a timely filing?
PAR providers contracting with Blue Cross Blue Shield must file claims within 365 days following the last date of service provided to the patient. This is referred to as
what is NCQA definition and what does it stand for?
The private, not-for-profit organization dedicated to improving health care quality and frequently referred to as the managed care watch dog
Which self-insured groups hire an organization to manage and pay claims?
Employee Retirement Services Administrator (ERSAs) and Administrative Service Organization (ASOs)
what are Fee-For-Sevices plans?
Policy premiums, yearly deductible adn coinsurance are the three out-of-pocket costs
What is a specialist?
A health care provider trained in a specific medical specialty is a
what organization accredits health care plans based on evaluating the quality of the patient?
A private, nonprofit organization that accredits health care given to plan members is teh
What is a referral?
A request by a health care provider for his or her patient to be evaluated or treated by a specialist is a
What is self-insurance?
When the employer - not an insurance company - is responsible for the cost of medical services, it is referred to as
what is consultation?
When a patient is sent to another provider (often a specialist) with the intent of rendering an expert opinion on a specific health complaint,
What is copayment?
With many MCOs, the enrollee typically pays a small fee upfront when visiting his or her PCP called a(n)
Explain Group insurance?
Many Americans obtain health insurance owing to their employment through what is commonly referred to as
What are the plain types within managed care plans?
Preferred Providers Organizations (PPO), Health Maintenance Organization (HMOs), Point-of-Service (POS) Plans
What is grievance?
The formal term for a written complaint submitted by an individual covered by a special plan or policy is called a
What is an utilization review?
To reduce unnecessary inpatient/outpatient services, managed care plan use
What is Fiscal intermediary?
Today, the Blue System is the largest sinle processor of Medicare claims, whihc are is called a
What is an Enrollee?
individuals who are members of a managed care plan are commonly referred to as
What is a PPO definition and what it stand for?
A group of health care providers working under one umbrella to provide medical services at a discount to the individuals who participate in the plan is referred to as a(n)
What is explanation of benefits?
A document pro pared by the carrier that gives details of how a claim was adjudicated is called a(n)
What is a primary care physician also known as PCP?
Members of a PPO normally do not have to chose a
What is an Utilization review?
A system designated to determine the medical necessity and appropriateness of a requested medical service or procedure is a(n)
What is an examples of staff model?
A multispecialty practice in which health care services are provided within the building complex owned by the Health Maintenance Organization (HMO) is referred to as a(n)
Members of a PPO normally do not have to chose a___________________?
Primary Care Provider