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Medical Insurance Key Terms Test 1

Terms in this set (17)

allowable charge
amount of a professional service fee that an insurance company is willing to accept.
birthday rule
insurance rule that states the policy of the parent whose birthday is first in the calendar year holds the primary insurance for any dependent.
capitation
managed care plan that pays a predetermined amount to a provider over a set time regardless of the number of services rendered to their subscribers in that period.
CHAMPVA
Civilian Health and Medical Program of the Department of Veteran Affairs; health benefits program that provides coverage to the spouse or widow(er) of a U.S. military veteran.
clearinghouse
organization that receives electronic claim forms from medical providers and processes them for payment.
CMS-1500
Health insurance claim form, also known as the "universal" claim form, that can be filed with all insurance companies; formerly HCFA-1500.
comprehensive plan
medical insurance plan that covers both basic and major medical costs.
coordination of benefits (COB)
insurance term stating that total reimbursement from primary and secondary insurance companies will not exceed the total cost of the charge.
co-payment
fixed fee that is paid by the patient at each visit.
cost containment
term referring to methods used to control the rising costs of health care.
curriculum vitae (CV)
type of physician's "resume" that lists education, in-service training (internship, residency), hospital affiliations, professional organizations, and any publications written.
explanation of benefits (EOB)
form sent by the insurance carrier to the patient and the medical practice that explains the amount of reimbursement or the reason for denial of a submitted claim.
fraud
intentional misrepresentation of medical facts as they relate to a claim for health care services.
gatekeeper
primary care physician designated by an HMO to provide ongoing care to a patient and to authorize referrals to specialists when deemed necessary.
HCFA Common Procedure Coding System (HCPCS)
standardized coding system that uses CPT, national, and local codes to process Medicare claims. Used primarily for supplies, materials, injections, and for certain procedures and services not defined in CPT.
Health Insurance Portability and Accountability Act (HIPAA)
federal legislation to improve health insurance availability those who lose coverage.
health maintenance organization (HMO)
organization that provides comprehensive health care services for plan participants at a fixed periodic payment.
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