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Patient To Payment
Terms in this set (35)
Assignment Of Benefits
Authorization by policyholder that allows a health plan to pay benefits directly to a provider.
The amount of money a health plan pays for services covered in an insurance policy.
The portion of charges that an insured person must pay for health care services after payment of the deductible amount;usually stated as a percentage.
An amount that a health plan requires a beneficiary to pay at the time of service for each health care encounter.
An amount that an insured person must pay, usually on an annual basis, for health care services before a health plan's payment begins.
A person other than the insured, such as a spouse or child, who is covered under a health plan.
A physician's opinion of the nature of patients' illnesses or injuries.
Payment for procedures that is made by an insurance company or a patient to a provider.
A health care claim that is transmitted electronically; also known as an electronic media claim (EMC).
A listing of the diagnoses, procedures, and charges for a patient's visit; also called the superbill.
Standards of conduct based on moral principles.
Standards of professional behavior.
Explanation of benefits (EOB)
A document from a payer sent to a patient that shows how the amount of a benefit was determined.
Method of charging under which a provider's payment is based on each service performed.
Health care claim
An electronic transaction or a paper document filed with a health plan to receive benefits.
Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care, including group health plan, health insurance issuer, health maintenance organization, Medicare Part A or B, Medicaid, TRICARE, and other governmental and nongovermental plans.
An insurance company's agreement to reimburse a policy holder a predetermined amount for covered losses.
Payment made to a provider by an insurance company on behalf of a patient.
Health plan; also known as insurance company, payer, or third-party payer.
A system that combines the financing and the delivery of appropriate, cost effective health care services to its members.
Managed care organization (MCO)
Organization offering some type of managed health care plan.
Medical office staff with specialized training who handle the diagnostic and procedural coding of medical records.
A financial plan that covers the cost of hospital and medical care due to illness or injury.
Medical insurance specialist
The person in a medical office who handles patient's health care claims.
Payment criterion of payers that requires medical treatments to be appropriate and provided in accordance with generally accepted standards of medical practice. The reported procedure or service (1) matches the diagnosis, (2) is not elective, (3) is not experimental, (4) has not been performed for the convenience of the patient or the patient's family, and (5) has been provided at the appropriate level.
Noncovered (excluded) services
A service specified in a medical insurance contract as not eligible for benefits.
Patient information form
A form that includes a patient's personal, employment, and insurance company data needed to complete a health care claim; also known as a registration form.
Insurance carrier; also known as insurance company, health plan, or third-party payer.
A person who buys an insurance plan; the insured, subscriber, or guarantor.
Prior authorization from a payer for services to be provided; if not received, the charge is not usually covered.
An illness or disorder of a beneficiary that existed before the effective date of insurance coverage.
The periodic amount of money the insured pays to a health plan for a health care policy.
Medical treatments and services provided by physicians and other licensed medical professionals.
A person or entity that supplies medical or health services and bills for is paid for the services in the normal course of business. A provider may be a professional member of the health care team, such as a physician, or a facility, such as a hospital or skilled nursing home.
Remittance advice (RA)
Health plan document describing a payment resulting from a claim adjudication; also called an explanation of benefits (EOB).
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