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Ch. 2 Medical Billing
Terms in this set (69)
Insurance purchased in the early 1900's to provide income replacement in the event of illness.
Insurance providing income to a policyholder who is disabled and cannot work.
A contract between the subsriber and the insurance company to pay for medical care and preventitive services.
Health insurance identification card
Card given to subscriber as proof of insurance.
A patient with no health insurance who must pay out of pocket for medical care.
The insurance plan that is billed first for medical services.
The insurance plan that is billed after the primary has paid or denied payment.
Another name for secondary insurance. This plan usually picks up the patients deductible and/or co-insurance.
Supplemental insurance for patients with Medicare as their primary. These plans may pick up the Medicare deductible and co-insurance.
The physician has signed a contract with the insurance company.
The number listed on the identification card that identifies the patient to the insurance company.
The number on the identification card that identifies the patient's employer group health plan.
A specific name assigned by the insurance company designating a specific plan for that type of insurance.
The person who has (carries) the health insurance.
Another term for policyholder.
Another term for policyholder or subscriber.
Term used for a patient who has Medicare coverage.
A flat fee the patient pays each time for medical services. This is associated with managed care plans.
A percentage the patient is responsible to pay of the cost of medical services. This is associated with indemnity, traditional, and commercial health insurance plans.
The amount the patient is responsible to pay before any reimbursement is issued by the insurance company. This is usually associated with indemnity, tradition, or commercial plans.
A type of insurance plan in which reimbursement is made at 80 percent of the allowed amount, and the patient pays the remaining 20 percent.
The dollar amount an insurance company deems fair for a specific service or procedure.
A list of allowed amounts for all services and procedures payable by the insurance company.
Another term for indemnity or commercial health insurance plans.
Another term for indemnity or traditional health insurance plans.
A health insurance plan funded by the goverment.
Centers for Medicare and Medicaid Services
(CMS) A goverment agency that oversees the Medicare and medicaid programs.
A goverment health insurance plan primarily covering persons aged 65 and older.
A goverment plan for financially indigent people.
Services performed at a facility where the patient stays less than 24 hours and is not admitted to the facility; also, the term for the patient recieving such services.
The Medicare plan in which reimbursement for most services and procedures is paid at 80% of the allowed amount.
A company that has contracted with CMS to pay Part B claims.
A company that contracts with CMS to pay Medicaid claims
A category listing requirements for a person to be covered by a specific plan.
Managed care plan
A health insurance plan that includes financing, management, and delivery of health care services.
Primary care provider
(PCP) A physician or other health care provider who is responsible for a patients main health care.
A physician who specializes in a particular area of medicine.
Medications prescribed by a physician or other liscensed prescriber.
Emergency room visits
An encounter in the emergency room.
Health maintenance organization
(HMO) A prepaid medical service plan that provides services to plan members.
Medical care sought by participating providers services to plan members.
Out of network
Medical care sought from nonparticipating providers; those providers who have not contracted with specific managed care plans.
An agreement between two or more parties.
System in which a physician is prepaid monthly for members enrolled in an HMO with which the physician has contracted. The payment is made to the physician regardless of whether the physician sees no patients or all the patients in this plan.
A monthly check the physician recieves from the HMO plan.
A list of patients enrolled in a particular HMO plan with which the physician is capitated.
A rate determined by the HMO for reimbursement for medical services when teh physician is capitated with that plan.
Fee for service
A payment system in which the physician is paid a specific amount for each service performed.
Preferred provider organization
(PPO) This type of plan offers discounts to insurance company clients in exchange for more members.
Out of pocket
The patients share the cost of health care services. This can include co-payment, co-insurance, or a deductible.
Point of service plan
(POS) A health insurance plan in which the patient pays a co-payment when staying in network.
A plan offered by managed care companies to replace Original Medicare as the patients health insurance.
Permission from the primary care physician to seek services from a specialist for an evaluation, testing, and/or treatment. Managed care plans require this.
The only Tricare plan offering coverage for active-duty service members. Retired members may also select this plan.
Military treatment facility
(MTF) A place where Tricare members recieve medical treatment
Preferred provider network
(PPN) A group of civilian medical providers that has contracted with Tricare.
A Tricare plan available only to retired military service members and their families. This plain is available both in the United States and oversees.
A Tricare plan available only to retired military service members and their families. This plan is not available oversees.
Existence and scope of existing health insurance
The one and only person covered under a health insurance plan.
A person employed who is covered under and employers group health plan.
(H/W) Health insurance covering both the husband and the wife.
Employee/significant other coverage
(E/S) Health insurance covering the employee's significant other.
Health insurance coverage for a parent and child.
Health insurance coverage for the individiual employee, the employee's spouse, and the employee's children.
Person covered under the policyholders plan.
Medical discount card
A card listing the patients name and verifying that the patient can recieve a discount on services, if the providers office participates.
A reduced fee.
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