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Insurance and Coding
| Question | Answer |
|---|---|
| Private insurance | provided by persons employer |
| primary insurance | insurance filed first and is the main insurance |
| premium | amount of money a person pays for their insurance |
| secondary insurance | double coverage (your work and parents insurance) |
| self insured | individual pays for insurance (people who are self employed) |
| self pay | people who have no coverage and would be expected to pay at the time of service. |
| government plans | special programs by state and federal government that provides insurance for the elderly, indigent and children |
| co-pay | specified sum of money based on patients insurance policy benefits due at the time of service |
| deductibles | specific amount of money a patient must pay out of pocket before the insurance carrier begins paying for service |
| explanation of benefits (EOB) | provided to patient by insurance company as a statement that details what services are paid, denied, or reduced in payment. EOB includes info that pertains to amount applied to the deductible, coinsurance or other allowed amounts. |
| co insurance | percentage of the total cost that an individual must contribute toward each service |
| remittance advice (RA) | EOB sent to provider from the insurance carrier. Similar to EOB, contains multiple patients and providers. Includes electronic funds transfer info or a check payment |
| advance beneficiary notice (ABN) | form that a Medicare patient will sign when the provider thinks Medicare wont pay for a specific service or item |
| medicare | pt 65 years and older for Part A ( hospitalization), Part B (routine office visits), Part D (prescription coverage) |
| tricare | authorized dependents of military personnel to see civilian practitioners |
| CHAMPVA | covers surviving spouses and dependent to see civilian practitioners |
| medicaid | health insurance to medically indigent population through a cost sharing program between fed government and states. |
| Workers Comp | state legislative law that protects employees against the cost of med care resulting from a work related injury |
| Children's health insurance program (CHIP) | offers low cost heath coverage for children from birth through 18. designed for families who earn too much to qualify for Medicaid but cant afford to buy private health coverage. |
| group policies | offered through an individual employer who will usually pay a portion of the premium and then deduct the remainder of the premium from the employees pay |
| individual policies | insurance plans that an individual funds themselves. patients might pay entire premium themselves of they are self employed |
| Health Maintenance Organization (HMO) | type of health insurance plan that usually limits coverage of care from doctors who work for or contract with the HMO. |
| HMO's | Health insurance plan that wont cover out of network care except in an emergency. |
| HMO's | health insurance plan that may require you to love or work in its service area to be eligible for coverage |
| Preferred Provider Organization | medical care arrangement in which med professionals and facilities provide services to subscribed clients at reduced rates |
| PPO | medical and healthcare providers are called preferred providers. |
| Health Savings Account (HSA) | saving account that can be used to pay for med expenses. funds are not taxed until time of withdraw and any amount not used stays in the account and accrues interest after a year. |
| Flexible Spending Account (FSA) | account funded with pretax dollars by an employee. don't roll over to the next year |
| ICD-10-CM | international classification of diseases. allows more specific reporting of diseases and newly recognized conditions |
| CMS-1500 form | claim form that is sent to the insurance company for review and payment. divided into sections and blocks that must be filled out correctly |
| referrals | doc or form required by insurance companies that used when a provider wants to send a patient to a specialist |
| participating provider | provider and insurance company have agreed between the amounts charged and approved and what will and wont be reimbursed |
| account balance | total amount owed on an account |
| debit | amount owed |
| accounts receivable | money owed to the provider |
| accounts payable | debts incurred and not yet paid |
| credit | monetary balance in an individuals favor |
| assets | entire saleable property of a person, Association, cooperation or estate applicable or subject to the payment of debts |
| liabilities | amount owed, debt |
| electronic Medical Record (EMR) | digital chart that is used in the facility |
| electronic health record (EHR) | includes EMR and other info to be used between more than one facility |
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