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24 terms

Commercial Insurance (COMP. 6/ Chapter 12)

Study guide for completing fee-for-service claims that are generally accepted nationwide by most commercial health insurance companies, including Athena, United Health Care, Prudential, Cigna, and others.
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Commercial health insurance
Covers the medical expenses of individuals (private health insurance) and groups (employer group health insurance).
Automobile insurance policy
Is a contract between an individual and an insurance company whereby the individual pays a premium and, in exchange, the insurance company agrees to pay for specific car-related financial losses during the term of the policy. Coverage typically includes the following; Collision, Comprehensivem, Emergency road service, liability, medical payments, personal injury protection, rental reimbursement, and underinsured motorist.
Medical adjuster
Reviews healthcare bills submitted to the insurance company for treatment of injuries sustained as the result of a motor vehicle accident to determine coverage.
Disability insurance
Covers reimbursement for income lost as a result of a temporary or permanent illness or injury. Disability insurance generally does not pay for healthcare services, but provides the disabled person with financial assistance.
Liability insurance
Is a policy that covers losses to a third party caused by the insured, by an object owned by the insured, or on premises owned by the insured. Liability insurance claims are made to cover the cost of medical care for traumatic injuries and lost wages, and, in many cases, remuneration (compensation) for the "pain and suffering" of the injured party. *health insurance benefits are secondary to liability insurance.
SSDI
Social Security Disability Insurance
Pays benefits to you and certain members of your familt if you are "insured," meaning that you worked long enough and paid social security income taxes.
SSI
Supplemental Security Income
Assistance to people with disabilities, pays benefits based on finacial need.
Base Period
Usually covers 12 months and is divided into 4 consecutive quarters. It includes taxed wages paid approximately 6 to 18 months before disability claim begins.
Subrogation
Refers to the contractual right of a third-party payer to recover healthcare expenses from a liable party.
Lien
Securing a debtor's property as security or payment for a debt.
EGHP
Employer group health insurance plan
Birthday Rule
States that the policyholder whose birth month and day occurs earlier in the calendar year holds the primary policy when each parent subscribes to a different health insurance plan.
NPI
National provider identifier
POS
Place of service
CLIA
Clinical Laboratory Improvement Amendments
Seconday health insurance
Plans provide coverage similar to that of primary plans
Supplemental health insurance
Usually cover only deductible, copayment, and coinsurance expenses.
PIP
Personal injury protection
Fee-for-service
Also known as indeminity insurance is traditional health insurance that covers a portion of services, such as inpatient hospitalizations or physician office visits with the patient paying the remaining costs.
High-risk pools
"last resort" health insurance for individuals who cannot obtain coverage due to a serious medical condition; certain eligibility requirements apply, such as refusal by at least one or two insurance companies.
Managed care
Health maintenance organization, preferred provider organization.
Association health insurance
Offered to members of a professional association and marketed to small business owners as a way to provide coverage to employees; however, these plans are subject to the same regulations as group health insurance plans and, therfore, are more risky.
EIN
employer identification number
SSN
social security number