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Module 150 Unit 2
Terms in this set (43)
Assignment of Benefits
Patient's authorization giving the insurance company the right to pay the physician directly for billed charges.
Used by insurance claims administrators to determine which parent's benefit plans will pay for the medical bills of a dependent child when the child covered by the plans of both parents.
An insurance reimbursement method in which the physician is reimbursed by the insurance company a flat "per head" fee per month for each patient who belongs to the medical group or practice, regardless of what or how many services the patient uses.
Written and documented request for reimbursement of an eligible expense under an insurance plan.
Health insurance claim for that has been completed correctly without any errors or omissions.
Independent entity that reviews claims, request clarification from the provider, and "cleans" claims, ensuring accurate information is documented, then submits claims to insurance companies in proper format.
Most common health insurance claim form used to file claims for physicians services.
A fixed percentage of charges the patient must pay under a given insurance plan.
Coordination of Benefits (COB)
Procedures to prevent duplication of payment by more than on insurance carrier.
Predetermined amount of money the patient must pay for medical services, as determined by the insurance company.
A recipient who is eligible for both Medicare and Medi-Cal, where Medicare pays a portion of the claim and Medi-Cal is billed for the remaining deductible and/or coinsurance.
Amount of eligible charges each patient must pay each calendar year before the insurance plan begins to pay benefits.
It occurs when procedures or services are not covered by the patients insurance policy or when the patient has not met his or her deductible; claim that was received by an insurance carrier but for which no payment was made.
A claim submitted with errors or one that require manual processing to resolve problems or is rejected for payment.
A program managed by the Social Security Administration that insures a worker in case of mishaps.
A process by which a health care provider submits a bill to a health insurance company for the rendering of medical services.
Exclusive Provider Organizations (EPOs)
A managed care contract with a smaller network of providers under which the employer agrees to not use any other networks in return for favorable pricing.
Lists the amounts to be paid by the insurance company for each procedure or service.
Programs and activities sponsored by local, state, or national governments
Health Maintenance Organizations (HMO)
Managed care plan in which a range of health care services provided by a limited group of providers (such as specific physicians or hospitals) are made available to plan members for a predetermined fee.
Health insurance claim for that has been completed but contains some type of incorrect information.
Insurance designed to cover medical expenses due to severe prolonged illness by paying all or most of the bills above a set amount.
A federal/state health insurance program primarily for low-income people.
A U.S. government health insurance program for which persons aged 65 and over and others with special conditions are eligible.
Medicare Part A
Hospital insurance that covers most care for patients who receive certain specialized services.
Medicare Part B
Covers such services as physician care, therapy, and laboratory testing on a fee-for-service basis.
A physician to whom the patient is expected to pay charges before submitting the claim to the insurance company, which pays the patient directly.
One who has a contractual agreement with an insurance plan to render care to eligible beneficiaries and then bill the insurance carrier directly.
Set of fees for services established by a health care provider and paid for by the patient.
Insurance plan in which a patient may choose an HMO or a non-HMO provider but must pay a deductible for using a non-HMO provider.
Requirement to obtain prior approval for surgery and other procedures from the insurance carrier in order to receive reimbursement.
Preferred Provider Organizations (PPOs)
An insurance arrangement that requires the patient to use a provider under contract to the insurance company, which reimburses the provider at a discounted rate.
Amount paid for insurance
Group of physicians or other health care providers who have a contractual agreement to provide services to subscribers on a negotiated fee-for-service or capitated basis; also called managed care plan
Primary Care Provider (PCP)
Gatekeeper provider who refers patients to other providers for services he or she cannot perform.
The insurance that pays first (primary payer) pays up to the limits of its coverage.
The practice of a physician ordering tests on a patient and that are performed by either the referring physician himself or a fellow faculty member from whom he receives financial compensation in return for the referral.
Federal program that provides health care benefits to families of current and retired military personnel.
A uniform institutional billing claim form used by hospitals, clinics, ambulatory surgery centers, rehabilitation centers, etc.
Usual, Customary, and Reasonable. Is an American method of generating health care prices
A period of time, designated by an insurance policy, that must elapse before coverage for specific services can begin.
Insurance carried by an employer that covers employees injured in the work place or off-site while conducting company business or suffering a workplace-related illness.
A cancellation from an account of a bad debt or worthless asset.
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