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INSURANCE TERMS
medical insurance and code terms
| Term | Definition |
|---|---|
| Private Insurance | Provided by a persons 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 parents 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 patients insurance policy benefits due at the time of the service. |
| Deductibles | a specified 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. also includes information that pertains to the amounts applied to the deductible, coinsurance or other allowed amounts |
| co-insurance | a percentage of the total cost that an individual must contribute toward each service (90%/10% or 80%/20%) |
| Remittance Advice (RA) | and 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 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 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 inservices-related disabilites |
| Medicaid | health insurance to the medically indigent population through a cost sharing program between federal government and states. Covers women of child bearing age and children. |
| workers compensation | a state legislative law that protects employees against the cost of medical care resulting from 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 |
| Government plans | Medicare, Medicaid, Tricare, CHAMPVA |
| 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 employees' pay. |
| individual policies | insurance plans that an individual funds themselves. Patients might pay the entire premium themselves if they are self -employed |
| networks | groups of provider that contract with an insurance company - usually results in better reimbursement if patients stay within the "network" |
| HMO (Health Maintenance Organization) | a health insurance plan that usually limits coverage of care from doctors who work for or contract with the HMO. won't cover-of-network care except in an emergency.HMO may require you to live or work in its service are to be eligible for coverage |
| 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) | 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. this must be used in conjunction with a high deductible plan. |
| Flexible Spending Account (FSA) | this account is funded with pretax dollars by an employee. do not roll over to the next year (fund lost if not used) |
| TYPE OF CLAIM ; paper copy or hard copy | is manually filled out and mailed to the insurance carrier |
| TYPE OF CLAIM : Electronic Claims | requires all the same information as the paper-based claim, but cane be processed through a direct billing system or a clearinghouse vendor to scrub (correct any potential mistakes) claims and remit for payment. |
| Chart Review | Consists of collection and clinical review of medical records to ensure that payment is made only for services that meet all plan coverage and medical necessity requirements. |
| VISIT TYPES : problem-focused | addresses an acute or chronic condition but requires a chief complaint. Documents history, exam, and medical decision making related to the condition. |
| VISIT TYPES : Detailed | can be for an acute or chronic condition but requires a chief complaint. Documents history, exam, diagnostic procedures, laboratory reports, and can even include for planning of in-office procedures. |
| VISIT TYPES : Comprehensive history | includes evaluation and/or an annual exam, addresses and assesses immediate needs and prepare patients to address any problems before they come up. |
| REFERRAL TYPES : regular Referrals | 3-10 business days for evaluation & approval |
| REFERRAL TYPES : Urgent Referrals | 24 hours to process |
| REFERRAL TYPES : stat Referrals | done by phones CNA can be approved immediately! |
| Participating Provider | this meant that the provider and the insurance company have agreed between the amounts charged and approved and what will and will not be reimbursed. |
| Account balance | the total amount owed on an account |
| Debit | an amount owned |
| Account receivable | money owed to the provider |
| Accounts payable | debts incurred and not yet paid |
| Credit | A monetary balance in an individuals favor |
| Assets | the entire salable property of a person, association corporation or estate applicable or subject to the payment of debts |
| Liabilities | amounts owed: debt |
| Pegboard system | the total for daily, weekly and monthly and yearly amounts are hosted on the side of the day sheet and easily available |
| Collections | before you can send any accounts to collections for non-payment, you must prove that you used all avenues for collection. |
| Aging Reports | Pulls a list of all accounts with a balance and then groups them together by a last payment or by date of service in categories of 0-30 days, 30-60 days, 60-90 days, and 90-120 days |
| spreadsheets | are used for reporting and the entering of information and the tracking of patient data, inventory and even personnel functions |
| network | a group of 2 or more computer systems that are connected together. You must take caution when accessing information from outside sources |
| Microsoft Word, Excel, PowerPoint and Outlook | these are word processing programs that are commonly used to create and modify documents |
| Data fields | A location where data is stored within a computer system |
| Electronic Medical Record (EMR) | this is a digital chart that is used in the facility |
| Electronic Health Record (EHR) | this includes the EMR and other information to be used between more than one facility |
Created by:
lillianamrangel
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