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Insurance Terms
| Term | Definition |
|---|---|
| Private Insurance | Proved by 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 parents insurance- the place you are employed comes first. "Birthday Rule" is which ever parents birthday comes first is used in the insurance. |
| Self Insured | Individuals pay for their insurance ( usually for people who are self- insured) |
| Self pay | People who have no coverage AKA Indigent - These people would be expected to pay at the time of insurance . 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 patients insurance policy benefits due at the time for 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 statement that details what services were paid, denied, or reduced in payment. An EOB also includes information that pertains to the amounts applied to the deductible, coinsurance/ allowed insurance |
| Co-insurance | A percentage of the total that an individual must contribute towards each services. 90/10 or 80/20 - The higher the premium, the lower the out-of-pocket-costs throughout the year |
| Remittance advice (RA) | An EOB sent to the provider from he insurance carrier. The RA contains multiple patients and Providers and it also includes 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 | Patients 65 years and older. Part A- hospitalization, Part B- Routine office visit, Part D- Prescription coverage |
| Tricare | Authorizes dependents for military personnel to see civilian practitioners. |
| CHAMPVA | Covers surviving spouses and dependent children of veteran who died in service |
| Medicaid | Health insurance to medically indigent population through a cost sharing program between 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 from work related injury |
| CHIP | Offers low cost health coverage for children from birth to age 18, designed for families who earn too much to qualify for Medicaid, but cannot afford to buy a private health coverage.- $35- $50/year |
| Group Policies | offered through an individuals 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 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 are contracted with the HMO. Generally won't cover out of network, except in an emergency |
| 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 (HAS) | A savings account that can be used to pay for medical expenses. These funds are not taxed until the time of withdraw. 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 because funds get lost if they are not used, |
| ICD-10-CM | Used for diagnosis testing. 3-7 characters the first character is always alphabetical then the rest ca be either alphabetical or numeric. |
| Upcoding | These are procedural coding they have 5 characters that are numeric and they are typically used in hospitals. |
| CMS-1500 form | A claim filled out for the insurance carrier so that can accept it. Can be submitted electronically must be timely within 12 months. Medicare only uses capital letters. |
| Referrals | A document or form required by the insurance companies that is used when when a provider wants to send patient to a specialist. |
| Participating Provider | The insurance and provider have agreed between the amount charged and approved and what will and will not be reimbursed |
| Account balance | The total amount owed on an account |
| Debit | An 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 | The entire saleable property of a person, association , corporation, or estate applicable or subject to payment of debts |
| Liabilities | Amounts owed; debts |
| Electronic Medical Record (EMR)/Electronic Health Record (HER) | EMR- is a digital chart that is used in the facility EHR- This includes the EMR and other information to be used between more than one facility |
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