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Billing
Health Insurance Terminology - Commercial FALL
| Term | Definition |
|---|---|
| allowable | maximum amount of money that many third-party payers allow for a specific procedure/service |
| actual charge | charge the physician submits for his services to the insurance carrier |
| authorization | number given by the insurance company authorizing approval of a procedure/service. Does not guarantee payment |
| beneficiary | person entitled to receive benefits from an insurance policy |
| birthday rule | insurance rule – when an individual is covered under two insurance policies, the policy holder whose birthday comes first in the calendar year, month and day, - not year – is primary/first payer |
| capitation | payment used by managed care plans; fixed payment is reimbursed to the provider for patients enrolled under his/her name |
| carrier | insurance companies that provide the policy and benefits |
| CHAMPVA | benefit program for the spouse and dependent children of veterans with service connected disabilities or of veterans who dies as a result of service connected disabilities |
| co-insurance | policy holder and insurance company share the cost of covered benefits (e.g. 80/20) |
| commercial insurance plans | also called private insurance – reimbursement is based on the policy |
| co-payment | sum of money paid at the time of medical service |
| deductible | fixed dollar amount that must be paid/met once a benefit year, before the insurance company begins to cover medical expenses |
| dependent | a person covered under the primary insured’s policy |
| effective date | date on which an insurance policy takes effect |
| exclusions | limitations on an insurance contract for which benefits are not payable |
| explanation of benefits | A claim summary indicating what services were covered, not covered and why, contains information on deductibles, co pays and allowed amounts |
| guarantor | person responsible for paying medical bill |
| participating provider | Physician who entered into a written contract with a specific insurance carrier and accepts their payment as payment in full and abides by their rules |
| referral | authorization for an HMO patient to be seen by a physician other than their PCP |
| tpa - third party administrator | Organization that processes claims for a health plan |
| TRICARE | government sponsored program under which dependents of active duty military personnel, retirees, and family members receive medical care |
| workers compensation | medical and disability insurance to cover employees in the event of a work related injury |
Created by:
a.adams
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