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Health Insurance ?s
Medical Terminology
| Question | Answer |
|---|---|
| Health insurance is a contract between | a policy holder and an insurance carrier |
| group insurance | a group of employees and their dependents are insured under 1 group policy issued to the employer |
| personal insurance | an insurance plan issued to an individual |
| pre-paid health plan | pre-determined set of benefits covered under one set annual fee |
| health maintenance organization (HMO) | a managed care benefits plan that provides a wide range of medical services to idividuals enrolled - must have a primary care physician |
| preferred provider organization (PPO) | like a HMO, but more flexiable - pay higher premiums - no primary care physician |
| point-of-service plan (POS) | managed care plan that gives beneficiaries the option whom to see for services. |
| Medicare Part A | covers hospital and hospice care |
| Medicare Part B | covers medical expenses for Dr visits and lab tests |
| Medicare Part D | covers prescription drugs |
| advance beneficiary notice | a document provided to a medicare beneficiary by a provider prior to service being rendered letting the beneficiary know of their responbility to pay if medicare denies the claim |
| medigap (medicare supplemental insurance) | this covers medical services that medicare denies (coinsurance) |
| blue cross | covers hospital services |
| blue shield | covers physician services |
| assignment of benefits | reimbursement is directly sent from payer to the provider |
| accept assignment | the provider agrees to accept what the insurance company approves as payment in full |
| fee-for-service | a fee that is charged for each procedure or service performed by the physician |
| fiscal intermediary | an insurance company that bids for a contract with CMS to handle the Medicare program in a specific area |
| premium | the cost of insurance coverage |
| deductible | out of pocket amount that must be paid annually |
| coinsurance | percentage of cost of the covered services that a policyholder or a secondary insurance pays |
| co-payment | a cost sharing requirement for the insured to pay at the time of service |
| coding | the process of converting diagnoses, procedures and services into numeric and alphanumeric characters |
| exclusions and limitations | conditions, situations and services NOT covered by the insurance |
| pre-certification | to determine the patient's benefits and the maximum dollar amount that the insurance company will pay |
| pre-authorization | a requirement for some health insurance plans to obtain permission for a service or procedure before it is done |
| qualified diagnosis | a working diagnosis which is not yet established |
| eligibility | the qualifying factor or factors that must be met before a patient receives benefits |
| coordination of benefits (COB) | when 2 insurance companies work together to coordinate payment of the benefits |
| peer review organization (PRO) | a state based group of physicians working under government guideline to review cases and determine their appropriateness and quality of professional care |
| civil monetary penalties law (CMPL) | law passed by the federal government to prosecute cases of medicaid fraud |
| remittance advice | an electronic or paper-based report of payment by the payer to the provider |
| patient's bill of rights | developed to promote the interests and well being of the patients and residents of the health care facility |
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