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Health Insurance 1
General questions about health insurance
| Question | Answer |
|---|---|
| What is a Administrative Services Only Contract (ASO)? | Contract between employers and private insurers under which employers fund the plan themselves, and the private insurers administer the plans for the employees. |
| What are timely filing requirements? | Filing deadlines that each insurance carrier has. |
| What is a Prior Approval Number? | A number indicating that the insurance company has been notified and has approved services before they were rendered. |
| What is Precertification? | A review that looks at whether the procedure could be performed safely but less expensively in an outpatient setting. |
| What is a Conditional Payment? | A payment the Medicare makes for services where another payer may be responsible. Payment is made so Medicare beneficiaries won't have to use their own money to pay the bill. |
| What is a Private Payer? | A private insurance company. Each company offers different types of plans that must meet or exceed basic standards set by the state and federal government. |
| What is a Commercial Payer? | Any healthcare policy that is not administered or provided by a governmental entity. Commercial Payers are allowed to offer whatever services they feel will make their plans more attractive to potential customers. |
| When does the tertiary insurance pay? | After the first and second insurers. |
| A managed care organization (MCO) that establishes a network of providers who are for their patients is called a _____________? | Preferred Provider Organization (PPO). |
| Physicians who enroll in managed care plans are called ___________. They have contracts with Managed Care Organizations (MCOs) that stipulate their fees. | Participating Providers. |
| Policy means: | insurance |
| Insurer/Insured, Subscriber, Member, and Recipient are all terms that apply to the ______________. | Policyholder |
| Person who is responsible for a patient's debt is the _____________. | Guarantor |
| True or False: PPOs never allow members to receive care from physicians outside the network. | False-policyholders may choose to go out of network, but they may have to pay greater expenses. |
| What is a Batch? | A group of submitted claims. |
| What is Cost-Sharing? | The balance a policyholder must pay to the provider. Generally includes deductibles, coinsurance, and copayments or similar charges, but it does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. |
| What is Allowable Charge? | An approved amount that insurance company will reimburse a provider for a certain medical expense. Often referred to as an approved charge or allowed amount. The allowable charge is the amount an insurance company is willing to pay for rendered services. |
| What is Actual Charge or Billed Amount? | The amount the provider charges for service. |
| Usual, Customary, and Reasonable (UCR) | The amount paid for medical service in a geographic area based on what providers in the area usually charge for the same or similar service. Sometimes used to determine allowable charge. |
| What is a Write-Off? | An amount that the provider has to remove from his books. |
| There are 2 types of Write-Offs. What are they? | Contractual write-off and Adjustments. |
| What is a Contractual Write-Off? | the difference between the billed amount and the system allowed amount will be the write-off if the EOB allowed amount is less than the system amount. Otherwise, the difference in billed amount and EOB allowed amount would be the write-off. |
| A provider is prohibited from billing a Medicare beneficiary for any _________________ identified with a CO group code, but may bill for any adjustment amount identified with a PR group code. | Adjustment (write-off) |
| What is the group code for Contractual Obligation? | CO-provider is financially liable |
| What is the group code for Correction and Reversal? | CR-no financial liability |
| What is the group code for Other Adjustment? | OA-no financial liability |
| What is the group code for Patient Responsibility? | PR-patient is financially responsible |
| What is a Copayment? | A fixed out-of-pocket amount paid by the insured person for covered services. |
| What is a Deductible? | The amount patient pays out-of-pocket before insurance pays benefits. |
| What does Out-of-Network mean? | Not contracted with the health plan. |
| What is an Out-of-Pocket Maximum? | A predetermined amount that patients pay after which the insurance company will pay 100% of the cost of medical services. |
| What is a Reimbursement? | Payment of services rendered from a third-party payer. |
| What is Reconciliation? | The process the billing office goes through to determine what payments have come in from the third-party payer and what the patient owes the provider. The billing office uses the RA, EOB, and MSN to make these determinations. |
Created by:
cattomko
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