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Insurance Terms
| 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 | amount of money that a person pays for their insurance |
| Secondary Insurance | double coverage (your work + parent's insurance) |
| Self Insured | individual pays for their insurance |
| 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 |
| Co-Pay | specified sum of money based on the pts insurance policy benefits due at the time of service |
| Deductibles | specific amount of money a pt must pay out of pocket before the insurance carrier begins paying for services |
| Explanation of Benefits (EOB) | provided to pt by insurance company as a statement that details what services were paid, denied, or reduced in payment |
| Co-Insurance | percent of total cost that an individual must contribute toward each service |
| Remittance Advice (RA) | an EOB sent to the provider from the insurance carrier; contains multiple pts and providers and electronic funds transfer info/ check for payment |
| Advance Beneficiary Notice (ABN) | form that Medicare pts will sign when the provider thinks Medicare won't pay for a specific service/ item |
| Medicare | pts 65+ for Part A (hospitalization), Part B (routine office visits), Part D (prescription coverage) |
| Tricare | authorities 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 the medically indigent population through a cost sharing program between federal government and states |
| Worker's Compensation | state legislative law that protects employees against the cost of medical care resulting from a work-related injury |
| Children's Health Insurance Policy (CHIP) | offers low-cost health coverage for children birth-18; designed for families who earn too much money for Medicaid, but cannot afford to buy private health coverage |
| 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; pts might pay the entire premium themselves if they are self-employed |
| Health Maintenance Organization (HMO) | health insurance plan that usually limits coverage of care from doctors who work fo/ contract with the HMO; generally won't cover out-of-network care except in an emergency; may require you to live/ work in its service area to be eligible for coverage |
| Preferred Provider Organization (PPO) | medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced rates; medical/ healthcare providers called preferred providers |
| Health Savings Account (HSA) | can be used to pay for medical expenses; funds are not taxed until the time of withdrawal, any amount not used stays in the account and accrues interest after a year; must be used in conjunction with a high deductible plan |
| Flexible Spending Account (FSA) | account funded with pretax dollars by an employee; do not roll over to the next year |
| ICD-10-CM | international classification of diseases; allows for specificity and laterality of coding for payment |
| Upcoding | type of fraud where healthcare workers submit inaccurate billing codes to receive inflated reimbursements |
| CMS-1500 | claim form sent to insurance companies for review and payment |
| Referrals | document/ form required by insurance companies that is used when a provider wants to send a pt to a specialist |
| Participating Provider | provider and insurance company have agreed between the amounts charged and approved and what will/will not be reimbursed |
| Account Balance | total amount owed on an account |
| Debit | an amount owed |
| Account Receivable | money owed to the provider |
| Accounts Payable | debts incurred and not yet paid |
| Credit | monetary balance in an individual's favor |
| Assets | entire saleable property of a person, association, corporation, or estate applicable or subject to the payment of debts |
| Liabilities | amounts owed; debt |
| Electronic Medical Record (EMR) | digital chart used in a facility |
| Electronic Health Record (EHR) | EMR+ other info to be used between facilities |
Created by:
baileedouglas
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