Terms in this set (25)
The health insurance policy owner or person who subscribes to the policy.
An additional person added to the policy by the subscriber, such as a spouse, dependent child, or other qualifying dependent relative.
The person, entity, program, grant, and/or agency responsible for the ultimate payment of the patient bill.
Any patient that is enrolled in a health insurance plan and receives benefits.
Primary Care Provider (PCP)
A health care professional (usually a physician) who is responsible for monitoring an individual's overall health care needs.
A predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers.
The amount an individual must pay for health care expenses before insurance covers any costs.
Refers to money that an individual is required to pay for services, after a deductible has been paid. Coinsurance is often specified by a percentage.
An insurance company that sponsors benefit plans.
A set of benefits that a payor offers to their members.
Represents a set dollar limit that you or your employer pay to a Health Maintenance Organization (HMO), regardless of how much you use (or don't use) the services offered by the health maintenance provider.
A system of health insurance payment in which a doctor or other health care provider is paid a fee for each service rendered.
An application for benefits provided by your health plan. A claim must be filed before funds will be paid to your medical provider.
Explanation of Benefits (EOB)
The insurance company's written explanation regarding a claim, showing what they paid and what the client must pay.
The date on which the patient's insurance coverage begins.
A group of doctors, hospitals and other health care providers contracted with a payer to provide services to subscribers for less than their usual fees.
A term assigned to patients who are financially responsible for the bill, typically without insurance coverage.
An agreement with states for assistance from the federal government to provide medical care for people meeting specific eligibility criteria.
A federal health insurance program that provides healthcare coverage for individuals aged 65 years and older or with certain qualifying disabilities.
Establishing the medical need for medical services
ABN--Advance Beneficiary Notice of Non-Coverage
Is a written notice that we give to a Medicare patient BEFORE they receive items or services which informs them that Medicare may not pay for their services.
Health Maintenance Organization
Is a plan that contracts with a medical center or group of physicians to provide preventive as well as acute care for the insured.
IPA--Independent Practice Association
An association of independent physicians, or other organizations that contract with independent physicians to provide services to managed care organizations on a negotiated rate.
Preferred Provider Organization
An insurer representing its clients contracts with a group of providers who agree on a predetermined list of charges for all services including those for both normal and complex procedures.
Point of Service
A "hybrid" plan that includes features of both HMO and PPO plans. The patient is assigned a PCP and network but can choose to go outside that network for treatment if they desire.