32 terms

Insurance Claim Vocabulary Terms

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claim
a submission to the insurance company for payment or reimbursement for services renderd to a patient
beneficiary
the person who benefits from the policy
out of pocket maximum
the max amount to be paid
lifetime maximum
the maximum amount the insurance company will pay in lifetime
Medical Saving accounts
Individual accounts that may be set up by self-employed individuals and those who work for
small companies. Funds in the accounts are used to pay medical expenses.
Coinsurance
amount paid for medical care after the deductible is met.
copay
flat fee paid by the patient in the office to receive medical care
deductible
amount paid by the patient before the insurance plan pays out on any claims.
Disability insurance
benefits paid to a patient in the event of injury or illness deeming them no longer able to work.
exclusions/ limitations
services that are not covered by a plan
fee-for-service insurance
traditional (indemnity) health insurance where you and your plan each pay a portion of your health expenses, usually after you meet a yearly deductible
flexible spending arrangements (FSA)
employees use pre-tax dollars to set up these accounts and draw down on them to pay qualified medical expenses during the year; unused amounts are forteited
Formulary
an insurance company's list of covered drugs
Group Insurance
Master health plan contract offered to a group of like individuals (employer, association, union, etc.) All having the same coverage.
Health Maintenance Organization (HMO)
form of managed care in which you receive all of your care from participating providers
health reimbursement arrangement
an account established by an employer to pay an employee's medical expenses; only the employer can contribute to the account
Health Savings Account (HSA)
an account established by an employer or an individual to save money toward medical expenses on a tax-free basis; remaining balance will "roll over"
high-deductivel health plan
provides comprehensive coverage for high-cost medical events; features high deductibles and a limit on annual out-of-pocket expenses
high-risk pool
a state-operated program that offers coverage for individuals who cannot get health insurance from another source due to serious illness
indemnity insurance
traditional, fee-for-service health insurance that does not limit where a covered individual can get care
individual health insurance
coverage purchased independently, usually directly from an insurance company, e.g. self employed
long-term care insurance
coverage that pays for all or part of the cost of home health care services or care in a nursing home or assisted living facility
managed care
an organized way of getting health care services and paying for care; feature a network of physicians, hospitals, and other providers who participate in the plan
medicaid
a federal program administered by the states to provide health care for certain poor and low-income individuals and families; eligibility varies by state
MEDICALLY NEEDY, recipients of AFDC/ SSI benefits
medicare
a federal insurance program that provides health care coverage to individuals 65 and older, disabled or Blind, permanent kidney failure, or who have had a kidney transplant
network
a group of physicians, hospitals, and other providers who participate or contracted in a managed care plan
open enrollment
a set time of year when y ou can enroll in health insurance or change from one plan to another without benefit of a qualifying event
point-of-service plan
form of managed care plan in which primary care physicians coordinate patient care but there is more flexibility in choosing doctors and hospitals than in an HMO
preferred provider organization (PPO)
form of managed care in which you have more flexibility in choosing physicians and other providers than in an HMO
Premium
amount you pay to belong to a health plan
primary care physician (PCP)
usually a family practice doctor, internist, ob-gyn, or pediatrician; s/he is your first point of contact with the health care system
usual,reasonable and customary (UCR)
the prevailing cost of a medial service in a given geographic area, established by the insurance company