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Chapter 14 Basics of Health Insurance
Terms in this set (58)
a recipient of health insurance benefits
a contract between the health insurance plan and the provider for which the health insurance plan will pay an agreed-upon monthly fee per patient and the provider agrees to provide medical services on a regular basis.
a document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, ad the patient's financial responsibilities.
a reimbursement model in which the health plan pays the provider's fee for every health insurance claim.
the primary care provider, 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, disabled, military, and indigent.
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 EOB.
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 qualify for medicaid for their secondary insurance.
Third-party administrator (TPA)
the intermediary and administrator who coordinates patients and providers, as well as processes claims, for self-funded plans.
the person who is the signer on the health insurance policy.
a process of managing health costs by influencing patient care decision making through case-by-case assessments of the appropriateness of care.
the amount of time a patient waits for disability insurance to pay after the date of injury.
The amount of money paid to keep an insurance policy in force is the:
The amount payable by an insurance company for a monetary loss to an individual insured by the company, under each coverage is called the:
Health insurance designed for military dependents and retired military personnel is called:
Veterans of the U.S. armed forces may be covered by:
A policy that covers a number of people under a single master contract issued to the employer or to an association with which they are affiliated and that is not self-funded is usually called _______ _________.
Organizations that fund their own insurance programs offer their employees _______ _______ plans.
Third party payer
Entities that make payment on an obligation or debt but are not parties of the contract that created the debt are called _____ ______ ______.
The maximum amount of money third-party payers will pay for a specific procedure or service is called the ______ ________.
The federal and state sponsored health insurance program for the medically indigent is called _______.
The physician who enters into a contract with an insurance company and agrees to certain rules and regulations is called a _________ provider.
A review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources is called ______ _______.
the amount of money the policy holder pays per claim or per accident toward the total amount of an insured loss before the company will pay on the claim is known as the _________.
access to specialized care and referral
Which of the following is not an advantage of managed care?
authorized services are normally covered
Which of the following is not a disadvantage of managed care?
independent practice association
Which type of HMO model consists of physicians with separately owned practices who formally organize into a group but continue to practice in their own offices?
young 23 year old
Which of the following would not normally be elligible for medicare?
physician office visit
Which of the following expenses would be paid for Medicare Part B?
Which part of Medicare covers prescription drugs?
A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called?
service benefit plan
Health insurance benefits are determined by:
The TRICARE option that is similar to a preferred provider network is TRICARE.
Which type of referral is usually processed immediately?
If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay, how much will his insurance pay on his bill of $4,359?
A payment method in which providers are paid for each individual enrolled in a plan, regardless of whether the person sees the provider that month, is called a ___________ plan.
Most of today's health insurance policies cover which of the following?
(True/False) Employee-sponsored group policies usually provide greater benefits at lower premiums because of the large pool of people from whom premiums are collected.
(True/False) However, these employee-sponsored group health insurance plans offer limited benefits, and healthcare access is limited to healthcare providers that are contracted with them.
Which of the following pays the hospital surgical room fee?
covers what medicare does not cover
Medigap polices cover which which of the following?
Verify insurance coverage
The MA should always verify which of the following prior to the patient's appointment?
Which of the following plans require healthcare providers to become participating providers?
Which of the following MCOs typically has/have the lowest monthly premiums with lower patient financial responsibilities?
Which of the following HMO models hires physicians and pays them a salary rather than contracting the physicians to create a network?
Which of the following referrals can be approved online when it is submitted through the provider's WEB portal to the utilization review department?
HMO PPO EPO
Which of the following managed care plans require preauthorization for medical services such as surgery?
Patient physician visit
Which of the following are not reviewed by a utilization review committee?
Dependents of military personnel are covered by which of the following government-sponsored health insurance plans?
Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium?
the electronic transfer of data between two or more entities
Electronic data interchange is:
To examine claims for accuracy and completeness before they are submitted is to ________ the claims.
special risk insurance
Insurance that protects a person in the event of a certain type of accident such as an automobile or plane crash is called:
Explanation of benefits
A document that explains what expenses where paid after submission to medicaid and sent to the physician's office is called
Independent practice association
Whitch type of HMO model consists of physicians with separately owned practices who formally organize into a group but continue to practice in their own offices
Whitch type of protection, formerly called catastropic insurance, provides coverage for especially large medical bills resulting from a prolonged illness?
Approximately ___% of people in the United States have no health insurance coverage.
When an individual is covered by two policies and the provider needs to know which policy is primary you refer to this.