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Chapter 14 Health Insurance Terms
A list of definitional terms that are need to know for Chapter 14
Terms in this set (51)
The maximum amount an insurer will pay for any give service
Assignment of Benefits
The authorization, by signature of the patient, for payment to be made directly by the patient's insurance to the provider for services.
Authorization to release medical information
A form that must be signed by the patient before any information may be given to an insurance company or any other third party
The health service provider
The third party
The insurance company
Person entitled to benefits of an insurance policy. This term is most widely used by Medicare
The health care provider is paid a fixed amount per member per month for each patient who is a member of a particular insurance organization regardless of whether services were provided
The Third Party. Term used to refer to insurance companies that reimburse for health care services.
Civilian Health and Medical Program of the Veterans' Administration (CHAMPVA)
Established for spouses and dependent children of veterans who have total, permanent, service-connected disabilities
The standard claim form designed by the Centers for Medicare and Medicaid Services to submit provider services for third-party payment
The percentage owed by the patient for services rendered after a deductible has been met and a copayment has been paid
Coordination of Benefits (COB)
Procedures insurers use to avoid duplication of payment on claims when the patient has more than one policy. One insurer becomes the primary payer and no more than 100 % of the costs are covered
A specified amount the insured must pay toward the charge for professional services rendered at the time of service
A predetermined amount the insured must pay each year before the insurance company will pay for an accident or illness
Diagnosis-related group (DRG)
A prospective payment system used by Medicare to classify illnesses according to diagnosis and treatment. DRG's group all charges for hospital inpatient services into a single bundle for payment purposes
the date when the Insurance policy goes into effect
Explanation of Benefits`
A printed description of the benefits provided by the insurer to the beneficiary
The action of health care providers informing patients of charges before the services are performed.
A list of predetermined payment amounts for professional services provided to patients
Term give to primary care providers because they are responsible for coordinating the patient's care to specialists, hospital admissions, ETC
Insurance offered to all employees by an employer
Health Maintenance organization (HMO)
Group insurance that entitles members to services provided by participating hospitals, clinics, and providers
Insurance purchased by an individual or family w no access to group insurance
The maximum amount a non participating provider can collect for services provided to a Medicare patient
Loss-of Income Benefits
Payments made to an insured person to help replace income lost through payment of the services
A joint funding program by Federal and State Governments for the medical re of LOW INCOME patients on ublic assistance
A federal program for providing health care coverage for individuals over the age of 65 or disabled
Medicare Fee Schedule
A list of approved professional services Medicare will pay for with the maximum fee if pays for each service
Private insurance to supplement Medicare benefits for payment of the deductible, copayment and coninsurance
A provider who has contracted to participate with an insurance company to be reimbursed for services
National Committee for Quality
A nonproﬁt organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector.
A provider who is not contracted with an insurer and can collect total
charges for services provided. Exception: Provider can collect only 115 percent of the Medicare Provider Fee Schedule allowed amount for Medicare beneﬁciaries.
The term used to identify services HMO members receive outside of their speciﬁed geographical area.
A provider who has contracted with an insurer and accepts whatever the insurance pays as payment in full.
Refers to a patient's eligibility for beneﬁts; the basis upon which beneﬁts are being provided (i.e., inpatient, outpatient, ER, ofﬁce etc.)
Point-of-service (POS) plan
An open-ended HMO, which delivers health care services using both a managed care network and traditional indemnity coverage. Care sought outside the managed care network results in higher out-of-pocket costs for the member.
Approval obtained before the patient is admitted to the hospital or receives speciﬁed outpatient or in-ofﬁce procedures.
A condition that existed before the insured's policy was issued.
Preferred provider organization (PPO)
A network of providers and hospitals that are joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers and their families for a discounted fee.
Monies paid for an insurance contract.
Relative Value Units
Numeric values assigned to payment components of the Resource-Based Relative Value Scale (RBRVS).
Resource-based relative value scale (RBRVS)
Fee schedule based on relative value units assigned for resources providers use to provide services for patients: provider work, practice expense, malpractice expense.
The geographic area served by an insurance carrier.
The person who has been insured; an insurance policy holder.
Third Party Payer
An insurance carrier who is not the doctor or patient but who intervenes to pay the hospital or medical bills per contract with one of the ﬁrst two parties.
TRICARE (Civilian Health and
Medical Program of the Uniformed
Established to aid dependents of active service personnel, retired service personnel and their dependents, and dependents of service personnel who died on active duty, with a supplement for medical care in military or public health service facilities.
Usual, customary, and reasonable (UCR) fee
The amount commonly charged for a particular medical service by providers in a speciﬁc geographical area; amounts are used to develop allowed amounts.
Utilization management (review)
A method of controlling health care costs by reviewing services to be
provided to members of a plan to determine the appropriateness and
medical necessity of the care prior to the delivery of the care.
A document outlining services that will not be covered by a patient's
insurance carrier and the cost associated with those services. Patient signature indicates that he or she understands that these services will not be covered and that he or she agrees to pay for the service out of pocket.
Government program that provides insurance coverage for those who are injured on the job or who have developed work-related disorders, disabilities, or illnesses.
Sets with similar terms
L-Q2-Ch 17-KT-Insurance and Billing
Medical insurance terms CMAA
Chapter 27-Health Insurance
Chapter 27 & 28
Other sets by this creator
AP Vocab Ch 21
AP Vocab Ch 20
AP Vocab Ch 19
AP Vocab Ch 18