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61 terms

Basics of Health Insurance ch. 3 key terms

Fordney
STUDY
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accounts receivable management
The organization and administration of coding and billing in a medical practice
applicant
person applying for insurance coverage.
assignment
A transfer, after an event insured against, or an individual;s legal right to collect an amount payable under an insurance contract
blanket contract
Comprehensive group insurance coverage through plans sponsored by professional associations for their members
capitation
A system of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amkount for each patient enrolled over a stated period regarless of the type and number of services provided. reimbursement to teh hospital on a per member per month basis to cover costs for the members of the plan. Capitation can also mean a set amount to be paid per claim.
The Civilian Health and Medical Program of the Department of Veteran Affairs,
( CHAMPVA), Civilian Health and Medical Program of the Department of Veterans Affairs, , a program for veterans with total, permanent, servic-connected disabilities or surviving spouses and dependents of veterans who died of service-connected disabilities
claim
A bill sent to an insurance carrier requesting payment for services rendered: also know as encounter record
coinsurance
(A.) A cost-sharing requirement under a health insurance policy providing that the insured will assume a percentage of the costs for covered services. (B.) For Medicare, after application of the yearly cash deductible, the portion of the reasonable charges (20%) for which the beneficiary is responsible. (C.) In the Medicaid Qualified Medicare Beneficiary program, the amount of payment that is above the rate that Medicae pays for medical services. The state assumes responsibility for payment of this amount
competitive medical plan
(CMP), A state licensed health plan similar to a health maintenance organization (HMO) hat delivers comprehensive, coordinated services to voluntarily enrolled members on a prepaid capitated basis, CMP status may be granted by the federal government for the enrollment of Medicare beneficiaries into managed cared plans, without having to qualify as an HMO
conditionally renewable
An insurance policy renewal provision that grants the insurer a limited right to refuse to renew a health insurance policy at the end of a premium payment period
coordination of benefits
(COB) Two insurance carriers working together and coordination the paymentof their benefits so that ther are no duplicatoin of benefits paid between the primary and secondary insurance carriers. In TRICARE, the coordination of the payment of TRICARE benefits with the payment of benefits made bya the double coverage plan, so that there is no duplication of benefits paid between the double coverage plan and TRICARE, likewise applied to disability programs
daysheet
A register for recording daily business transactions(charges, payments, or adjustments); also known as daybook, daily log, or daily record sheet, r.
deductible
A specific dollar amount that must be paid by the insured before a medical insurance plan or government program begins covering health care costs.
disability income insurance
A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease-not as a result of a work-related accident or condition
electronic signature
An individualized computer access and identification system(e.g. a series of numbers, letters, electronic writing, voice, computer key, and fingerprint transmission {biometric system}) accepted by both parties to show intent, approval of, or responsibility for computer document content.
eligibility
Qualifying factors that must be met before a patient receives benefits under a specified insurance plan, government program, or managed care plan.
emancipated minor
A person younger than 18 years of age who lives independently, is totally self-supporting, and possesses decision-making rights.
encounter form
An all-encompassing billing form personalized to the practice of the physician, it may be used when a patient submits an insurance billing: also called charge slip, communicator, multipurpose billing form, fee ticket, patient service slip routing form, superbill, and transaction slip
exclusions
Provision written into the insurance contract denying coverage or limiting the scope of coverage.
epo
(EPO), A type of managed health care plan that combines features of HMOs and PPOs. It is referred to as "exclusive" because it is offered to large employers who agree not to contract with any other plan. EPOs are regulated under state health insurance laws
expressed contract
a written or verbal agreement.
extended
To carry forward the balance of an individual financial accounting record.
financial accounting record
An individual record indicating charges, payments, adjustments, and balances owed for services rendered, also known as a ledger
foundation for medical care
(FMC), An organization of physicians sponsored by a state or local medical association concerned with the development and medical services and cost of health care.
guaranteed renewable
A clause in an insurance policy that means the insurance company must renew the policy as long as premium payments are made. However, the premium may be increased when it is renewed. These policies may have age limits of 60, 65, or 70 years or may be renewable for life.
guarantor
an individual who promises to pay the medical bill by signing a form agreeing to pay or who accepts treatment consitiutes and expressed promise
health insurance
A contract between the policyholder or member and insurance carrier or government program to reimburse the policyholder or member for all or a portion of the cost of medical care rendered by health care professionals; generic term applying to lost income arising from illness or injury
health maintenance organization
(HMO),
high risk
A high chance of loss
implied contract
Beneftis paid to an insured while disabled.
indemnity
Beneftis paid to an insured while disabled. also know as reimbursement.
independent or individual practice association
(IPA) TLTT
insured
An individual or organization protected in case of loss under the terms of an insurance policy
major medical
Health insurance policy designer to offset heavy medical expenses resulting from catastrophic or prolonged illness on injury
Maternal and Child Health Program
(MCHP) A state service organization to assist children younger than 21 years of age who have conditions leading to health problems
Medicaid
(MCD),, a federally aided, state-operated an -administered program that provides medical benefits for certain low-income persons in need of health and medical care
Medicare
(M), A nationwide health insurance program for persons 65 years of age or older and certain disabled or blind persons regardless of income, regardles of income, administered by CMS. Local Social Security offices take applications and supply information about the program
Medicare/ Medicaid
(Medi-Medi)
member
TLTT
noncancelable policy
TLTT
nonparticipating provider
(nonpar), a provider who decides not to accept the detemined allowable charge from an insurance plan as the full fee for care. Payment goes directly to the patients in this case, and the patient is usually responsible to pay the bill in full.
optionally renewable
An insurance policy renewal provision in which the insurer has the right to refuse to renew the policy on a date and may add coverage limitations or increase premium rates
participating provider
(par) One who accepts TRICARE assignment. Payment in this case goes directly to the provider. The patient must still pay the cost-share outpatient deductible and the cost of care not covered by TRICARE.
patient registration form
A questionnaire designed to collect demographic data and essential facts about medical insurance coverage for each patient seen for professional services
personal insurance
An insurance plan issued to an individual (or his or her dependent): also know as individual contract
point-of-service plan
(POS) plan, A managed care plan in which members are given a choice as to how to receive services, whether through an HMO, PPO, or fee-for-service plan. The decision is made at the time the service is needed (e.g. "at the point of service"): sometimes referred to as open-ended HMOs, swing-out HMOs, self-referral options, or multiple option plans
posted
To record or transfer financial entries, debit or crdit, to an account (e.g., daysheet, financial account record [ledger], bank deposit slip, check register, or journal.
preauthorization
A requirement of some health insurance plans to obtain permission for a service or procedure before it is done to see whether the insurance program agrees it is medically necessary
precertification
This is done to determination whether treatment (surgery, test, or hospitalization) is covered under a patient's insurance policy; required by many insurance companies
predetermination
this is done to determine the maximum dollar amount the insurance company will pay for surgery, consultations,postoperative care, and so forth
preexisting conditions
Illnesses or injuries acquired by the patient before enrollment in an insurance plan. In some insurance plans, preexisting conditions are excluded from coverage temporarily or permanently or may disqualify membership in the plan.
preferred provider organization
A
premium
The cost of insurance coverage paid annually, semiannually, or monthly to keep the policy in force. In the Medicare program, monthly fee that enrollees pay for Meicare Part B medical insuance. This fee ins updated annually to reflect changed in program costs.
running balance
An amount owed on a credit transaction; also known as outstanding or unpaid balance.
State Disability Insurance
(SDI) See Unemployment Compensation Disability
subscriber
The contract holder covered by an insurance program or managed care plan, who either has coverage through his or her place of emplyment or has purchased coverage directly from the plan or affiliated. This term is used primarily in Blue Cross and Blue Shield plans.
TRICARE
A three-option managed health care program offered to spouses and dependents of service personnel with uniform benefits and fees implemented nationwide by the federal government
Unemployment Compensation Disability
(UCD) Insurance that covers off-the-job injury or sickness and is paid for by deductions from a perso's payness and is paid for by dedcutions from a person's paycheck. This program is administered by a state agency and is sometimes also known as State Disability nsurance (SDI) or temporary disabilty insurance (TDI)
Veterans Affair (VA) outpatient clinic
A clinic where medical and dental services are rendered to veterans who have service-related disabilities
worker's compensation insurance
An individualized program of therapy using simulated or real job duties to build up strength and improve the worker's endurance to be able to work up to 8 hours perday. Sometimes work site modifications are instituted ti get the employee back to gainful employment.
contract
A legally enforceable agreement when relating to an insurance policy : for workers compensation cases, an agreement involving two or more parties in which eash is obligated to the other to fulfill promises made. (The contract exists between the physician and the insurance carrier.