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Insurance Terms
| Question | Answer |
|---|---|
| Private Insurance | Provided by a person's employer |
| Primary insurance | Insurance that is filed first and is the main insurance for a person |
| Premium | The amount of money that a person pays for their insurance |
| Secondary insurance | Double coverage (your work and your patient's insurance) |
| Self insured | Individual pays for their insurance (usually for people who are self employed) |
| Self pay | People who have no coverage and would be expected to pay at the time of service. Some places will offer special pricing for self paying individual |
| Government plans | Special programs by state and federal government that provides insurance for the elderly, indigent, and for children |
| Co- pay | a specified sum of money based on the patient's insurance policy benefits due at the time of service |
| Deductibles | a specific amount of money a patient must pay out of pocket before the insurance carrier begins paying for services. Deductible amounts are usually on a calendar year accrual basis |
| Explanation of benefits (EOB) | Provided to the patient by the insurance company as a statement that details what services were paid, denied, or reduced in payment. An EOB also includes information that pertains to the amounts of applied to the deductible coinsurance or other allowed |
| Co-insurance | A percentage of the total cost that an individual must contribute toward each service (I.e 90% 10%, 80%, 20%) |
| Remittance advice (RA) | an EOB sent to the provider from the insurance carrier. Is similar to the EOB, the RA contains multiple patients and providers. Also includes the electronic funds transfer information or a check for payment |
| Advance beneficiary notice (ABN) | A form that a medicare patient will sign when the provider thinks medicare wont pay for a specific service or item |
| Medicare | Patient 65 years and older for part A (hospitalization) Part B (routine office visits), part D (prescription coverage) |
| Tricare | Authorizes dependents of military personnel to see civilian practitioners |
| CHAMPVA | covers surviving spouses and dependent children of veterans who died in service related disabilities |
| Medicaid | Health insurance to a medically indigent population through a cost sharing program between the federal government and states. Covers women of child bearing age and children |
| Worker's compensation | a state legislative law that protects employees against the cost of medical care resulting form a work- related injury |
| CHIP children's health insurance program | offers low cost health coverage for children from birth through age 18. Designed for families who earn too much to qualify for Medicaid, but cannot afford to buy private health coverage. $35-$50/year. |
| Group policies | offered through an individual's employer who will usually pay a portion of the premium and then deduct the remainder of the premium from the employee's pay |
| Individual policies | Insurance plans that an individual funds themselves. Patients might pay the entire premium themselves if they are self-employed |
| HMO (Health Maintenance Organization) | A type of health insurance plan that usually limits coverage of care from doctors who work for or contact HMO. It generally won't cover out of network care except in an emergency. An HMO may require you to live or work in its service area to be eligible |
| PPO (Preferred Provider Organization) | A medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced rates. PPO medical and healthcare providers are called preferred providers. |
| Health Savings Account (HSA) | A savings account that can be used to pay for medical expenses. These funds are not taxed until the time of withdrawal. Any amount not used stays in the account and accrues interest after a year. |
| Flexible Spending Account (FSA) | This account is funded with pretax dollars by an employee do not roll over to the next year (funds lost if not used) |
| CD-10-CM | This is the procedure coding system composed of medical classifications for procedural codes. This is typically used in hospitals that record various health treatment and tests |
| Upcoding | The practice of assigning a higher billing code or level of service to a medical procedure or service than what was actually provided. |
| CMS-1500 form | The claim form that is sent to the insurance company for review and payment |
| Referrals | A document or form that is sent to the insurance company for review and payment |
| Participating Provider | This means that the provider and the insurance company have agreed between the amount charged and approved |
| Account balance | the total amount owed on an account |
| Debit | an amount owed |
| Accounts receivable | money owed to the provider |
| Accounts payable | Debits incurred and not yet paid |
| Credit | A monetary balanced in an individual's favor |
| Assets | The entire salable property of a person association corporation or estate applicable or subject the payment of debts |
| Liabilities | Amounts owed debt |
| Electronic Medical Record (EMP)/Electronic Health Record (HER) | A digital chart that is used in the facility, this includes the EMR and other information to be used between more one facility. |
Created by:
Alejandronoguerol
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