Basics of health insurance kinns chapter 14

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Terms in this set (...)

Beneficiary
A recipient of health insurance benefits
Capitation
Contract between the health insurance plan and the provider for which the health insurance plan will pay an agreed-upset n monthly fee per patient and the provider agrees to provide medical services on a regular basis
Explanation of benefits (EOB)
A document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services and the patients financial responsibilities
Fee-for-service
A reimbursement model in which the health plan pays the providers fee for every health insurance claim
Gatekeeper
Primary care giver, who can approve or deny when the patient seeks additional care via a referral to a specialist or further medical tests
Government sponsored health insurance
Health insurance programs that are sponsored by the government and offer coverage for the elderly,disable, military, indignant
Online provider insurance web portal
An online service provided by various insurance companies for providers to look up patient insurance benefits, eligibility, claims status and explanation of benefits
Privately sponsored health insurance
Health insurance companies that operate for profit and use managed care plans to reduce the costs of healthcare
Qualified Medicare beneficiaries (QMB)
Low income Medicare patients who quality for Medicaid for their secondary insurance
Third party administrator (TPA)
The intermediary ad administrator who coordinates patients and providers, as well as processes claims, for self funded plans
Subscriber
Yeah person who is the signer on the health insurance policy
Utilization management
Process of managing healthcare costs by influencing patient care decision making through case-by-case assessments of the appropriateness of care
Waiting period
The amount of time a patient waits for disability insurance to pay after the date of injury
Regular referral
3-10 working days for review and approval. Used when the provider believes that the patient must see a specialist to continue treatment
Urgent referral
Usually takes up to 24 hours for approval this type of referral is used when an urgent but not life threatening situation occurs
A STAT referral
Can be approved online when submitted to the utilization review departments through providers web portal. Used for emergencies