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insurance terms
insurance terms and definitions
| Term | Definition |
|---|---|
| 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 (ex your work and your parent'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 program 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 usally 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 EBO aslo includes information that pertains to the amount applied to the deductible, coinsurance or other allowed aount |
| Co-insurance | a percentage of the total coast that an individual must contribute towards 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 provider. also including 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 service or item |
| Medicare | patients 65 years and older for part A (hospitalized) part B (routine office visits), part D (prescription coverage) |
| Tricare | authorizes dependent 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 the medically indigent population through a cost sharing program between federal government and state. 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 a work-related injury |
| CHIP | offer low-cost health coverage for children from birth through age 18. designed for families who earn too much to qualify for medicaid, but cannot affored to buy 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 plan 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 contract with the HMO. it generally wont cover out-of-network care except in an emergency. an HMO may require you to live or work in its service area to be |
| 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 stays in the account and accrue interest after a year, this must be used in conjunction with a high deductible plan. contribytion can be made by the individual or th |
| Flexible Spending Account (FSA) | this account if funded with pretax dollars by an employee. do not roll over to the next year ( funds lost if not used) |
| ICD-10-CM | -uses 3-7 characters -was implemented on October 1st of 2015 -first character is alphabetical -international classification of diseases |
| Upcoding | billing for more expensive service than the one actually performed |
| CMS-1500 form | Standard insurance form used by all government and most commercial insurance payers. Is divided into sections and blocks that must be filled out correctly. |
| Referrals | a document or form required by insurance companies that is used when a provider wants to send a patient to a specialist |
| Participating Provider | this means that the provider and the insurance company 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 | a monetary balance in an individual favor |
| Assets | the entire salable property of a person, association corporation or estate applicable or subject to the payment of debt |
| Liabilities | amount owed; debt |
| Electronic Medical Record (EMR)/Electronic Health Record (HER) | EMR- this is a digital chart that is used in the facility HER- this includes the EMR and other information to be used between more than one facility |
| networks | groups of providers that contract with an insurance company- usually results in better reimbursement if patients stay within the network |
| CMS-1500 | most common health insurance claim form used to file claims for physicians' services and reimbursement |
Created by:
Paloduro
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