Upgrade to remove ads
Terms in this set (40)
Payment method based on provider charges
Type of medical insurance that reimburses a policy holder for medical services under the terms of its schedule of benefits
Illness or disorder of a beneficiary that existed before the effective date of insurance coverage
Monies owed to a medical practice by its patients and third party payers.
The practice's operating expenses, such as for overhead, salaries, supplies, and insurance
The number assigned to a diagnosis in the International Classification of Diseases
Actions that satisfy official guidelines and requirements
Payment method in which a prepayment covers the provider's services to a plan member for a specified period of time.
Primary Care Physician
A physician in a health maintenance organization who directs all aspects of a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper
Record of all charges, payments, and adjustments made on a particular patient's account
An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan's payment begins.
The movement of monies into or out of a business
Consumer-Driven Health Plan
Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses
Revenue Cycle Management (RCM)
All actions taken to make sure that sufficient monies flow into the practice from patients and insurance companies paying for medical services to pay the practice's bills.
Medical Insurance Specialist
Medical office administrative staff member who handles billing, checks insurance, and processes payments.
Medical Billing Cycle
A series of steps that lead to a maximum, appropriate, timely payment for patients' medical services.
The process followed by health plans to examine claims and determine benefits
Electronic Health Record (EHR)
A computerized lifelong healthcare record for an individual that incorporates data from all sources that provide treatment for the individual.
Person who buys an insurance plan; the insured, subscriber, or guarantor or member.
An amount that a health plan requires a beneficiary to pay at the time of service for each healthcare encounter
Description of a provider who does not have a participation agreement with a plan
System that combines the financing and the delivery of appropriate, cost-effective healthcare services to its members.
Payment criterion of payers that requires medical treatments to be clinically appropriate and provided in accordance with generally accepted standards of medical practice. To be medically necessary, the reported procedure or service must match diagnosis, be provided at the appropriate level, not be elective, not be experimental, and not be performed for the convenience of the patient or the patient's family.
An electronic transaction or a paper document filed with a health plan to receive benefits.
Health Maintenance Organization (HMO)
A managed healthcare system in which providers agree to offer healthcare to the organization's members for fixed periodic payments from the plan; usually members must receive all medical services from the organization
The recognition of a person demonstrating a superior level of skill on a national test by an official organization
Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers, health maintenance organizations, Medicare part A or B, or Medicaid
Preferred Provider Organization (PPO)
Managed Care organization structured as a network of healthcare providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge.
Financial plan that covers the cost of hospital and medical care
Person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business. A provider may be a professional member of the healthcare team, such as a physician, or a facility, such as a hospital or skilled nursing home.
Contractual agreement by a provider to provide medical services to a payer's policyholders
Private or government organization that insures or pays for healthcare on the behalf of beneficiaries; the insured person is the first party, the provider the second party, and the payer the third party
Preventative Medical Services
Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests
Portion of charges that an insured person must pay for healthcare services after payment of the deductible amount; usually stated as a percentage
Transfer of patient care from one physician to another
Money the insured pays to a health plan for a healthcare policy
The amount of money a health plan pays for services covered in an insurance policy
Treatments specified in a medical insurance contract as not covered
Medical procedures and treatments that are included as benefits under an insured's health plan
Advance permission from a payer for services to be provided; if the permission is not received , the charge is usually not covered.
THIS SET IS OFTEN IN FOLDERS WITH...
CBCS Exam Study Guide
NHA Billing & Coding - Ch 4 - Claims Processing/Co…
CMS 1500 Claim Form
YOU MIGHT ALSO LIKE...
Medical Insurance Chapter 1 Vocab
Medical Insurance Chapter 1
Medical Billing, Coding, and Insurance-Chapter 1
Medical Insurance Chapter one
OTHER SETS BY THIS CREATOR