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Business Pr. INS
Chapter 18/ch 16 Review of Insurances
| Term | Definition |
|---|---|
| ajudicate | Determination for monetary settlement or payment |
| third-party payer | Insurance carrier is it intervenes to be hospital or medical expenses on behalf of beneficiaries for recipients |
| indemity | Benefits paid in a predetermined amount in the event of a covered loss |
| deductible | Amount the insured must pay in a calendar of the school year before insurance company begins the payment of benefits |
| carrier | Organization that offers protection against losses in exchange for premium |
| adjuster | Employee of the Worker's Compensation insurance carrier with the case is assigned a new follows the case until it is settled |
| premium | Periodic payment made to keep an insurance policy in force |
| eliminations period | . Of time after the beginning of a disability for which no benefits are payable |
| fiscal intermediary | Contractor that processes payments to providers on behalf of state or federal agencies or insurance companies |
| partial disability | Illness or injury preventing the insured from performing one or more functions of his or her occupation |
| total disability | Illness or injury prevent a person from performing his or her job, or any other work |
| permanent disability | Illness or injury temporarily not allowing a person to do their job |
| The four main stages of the lifecycle of an insurance claim | Submission, processing, adjudication, payment |
| What types of commercial health insurance plans | MCP, self-pay, indemity |
| HDHP | abbreviation for insurance plan w high deductible |
| true or false...Medicaid coverage benefits are the same across all states | FALSE |
| true or false..each state operates its own Medicaid program | True |
| Three Types of Tricare | Standard, Extra, Prime |
| Medigap insurance policies are oofered by ____________ and controlled by the ______________ | MCP, Government |
| Stark Regulation 1&2 | a doc cannot refer/send a pt to another doc/facility associated w that doc who is their family |
| CHAMPVA is a military service benefit program for | Retired and honor ably discharged no premium |
| an attachment to a policy excluding certain illnesses or disabilities is called | waivers |
| birthday plan | The rule most states use when a child is covered by both parent's health insurance determine primary |
| Elimination period is also known as the | Waiting period, expected |
| CMS-1500 form | I may only be optically scan from the original copy, uses red ink HIAA |
| Claim scrubber | A service that receives insurance claims Addison sort them and electronically transmit them to ins companies |
| The standard unique help identify her that all healthcare providers use when submitting claims is called the | NPI |
| Pre-authorization is for | Medications, referrals, records,surgery |
| Pre-certification is for | Procedures |
| Predetermination determines | Money.. How much a service will be paid for |
| RBRVS | Medicare |
| FECA | Federal employee compensation act |
| Document that arrives from the Ins. company with insurance claim | EOB, if Medicare its RA |
| Reasonable fee | Usual, customary, justifiable |
| Usual fee | Amount for a certain demographic |
| Group model | HMO- individual |
| Staff model | HMO- physician hires, pays salary |
| Network model | HMO- plan with two or more practices |
| HSA FSA | Tax deferred contribution |
| Total and partial | Off job disability |
| Contractor processes payments to physicians on the half of state , federal | MCO |
| The time limit for submission of a Medicare claim | One fiscal year |
| Patient qualifies for Medicare and Medicaid is referred to as a | Medi medi |
| And attachment to a policy excluding certain illnesses or disabilities is called a | Waiver |
| The insured is also known as a | Policyholder recipient member subscriber |
| Under Workmen's Comp. two terms for permanent disability | Permanent and stationary, residual |
| AHIP government plan | Americas health insurance plans |
| A referral where the doctor direct directly tells the patient | Direct |
| A referral that is in writing and a letter or email | Formal |
| A referral when the doctor calls | Verbal |
| A referral where The patient calls the PCP | Self |
| Oldest of pre-paid plans as a gatekeeper and yearly c apitation usually no out of network benefits | HMO |
| Freedom of choice you know gate fee for out of network benefits usually needs pre-Certs and pre-auth | PPO |
| Like an HMO only there is a monthly capitation as opposed to yearly | IPA |
| IPA and HMO pays for ambulatory service PPO pay for hospital service | PPG |
| Combination plan HMO and PPO | POS |
| Partial and total disability by the state | SDI |
| Temporary and permanent disability when your hurt at work | Workers compensation |
| Participating Medicare is | Contracted |
| Non participanting Medicare is | Not contracted |
| Limit charge Medicare is | Not contracted, urgent care |
| "A"Medicare covers | Hospital |
| "B" Medicare covers | Ambulatory/office visits |
| "C" Medicare covers | Advantage plan A and B dental and vision |
| "D" Medicare covers | Medicine |
| Always secondary insurance and sponsored by state local federal governments, for poor and disabled | Medicaid |
| 60% insurance pays, 40% pt pays | Bronze |
| 80% insurance pays, 20% pt pays | Gold (higher premium, lower out of pocket) |
| 70% insurance pays, 30% pt pays | Silver (fair plan) |
| 65 and older,ABCD ins, bronze silver gold plan | Medicare |
| The term third-party pairs indicates the following are involved in healthcare reimbursement | Patient provider and payer |
| State insurance exchanges | I called market places, offer insurance based on gender age and location, or offered in every state and maybe used by all noncitizens residing in the US |
| The parent whose birthday falls earlier in the calendar year by month will pay for in a health care plan is part of the | Birthday rule |
| State disability is available in | California Hawaii New Jersey New York and Rhode Island |
| Get a workers comp case the medical assistant communicates with | Adjuster |
| The CMS 1500 claim form has an assignment of benefits for government programs in | Field 12 |
| CMS-1500 is in red to | Comply w OCR machines |
| When comparing electronic versus paper claim submission the average processing time is | 28 to 30 days for paper and 7 to 10 days for electronic |
Created by:
Gmtassa23
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