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Insurance Terms
| Term | Definition |
|---|---|
| Private Insurance | Provided 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 (ex, your work and your parent's insurance). The place you are employed is primary. |
| 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 individuals. |
| 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. Also includes information that pertains to the amounts applied to the deductible, co-insurance, or other allowed amounts |
| Co-insurance | Percentage of the total cost that an individual must contribute toward each service |
| Remittance Advice (RA) | An EOB sent to the provider from the insurance carrier. Similar to EOB, it contains multiple patients and providers; includes electronic funds transfer information or a check for payment |
| Advance Beneficiary Notice (ABN) | Form that a Medicare patient will sign when the provider thinks Medicare won't pay for a specific service or item |
| Medicare | Patients 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 the 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 a work-related injury |
| CHIP | Children's Health Insurance Program = offers low cost heath coverage for children from birth through age 18. Designed for families who earn too much to qualify for Medicaid, but can't afford to buy private health coverage. 35-50$/yr |
| 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) | Type of health insurance plan that usually limits coverage of care from doctors who work for/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, |
| PPO (Preferred Provider Organization) | A medical care arrangement in which medical professionals and facilities provide services to subscribed clients at reduced rates. PPO's medical and healthcare providers are called preferred providers. |
| Health Savings Account (HAS) | Savings account that can be used to pay for medical expenses. 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 w/ high deductible plan. |
| Flexible Spending Account (FSA) | Funded with pretax dollars by an employee. Do not roll over to the next year (funds lost if not used) |
| ICD-10-CM | International Classification of Diseases; Allows more specific reporting of diseases and newly recognized conditions; 3-7 characters. 1st - alphabetical, 2-3rd = numeric, rest = either; allows for specificity and laterality of coding for payment |
| Upcoding | when a healthcare provider submits codes to Medicare, Medicaid, or private insurers for more serious (and more expensive) diagnoses or procedures than the provider actually diagnosed or performed. |
| CMS-1500 form | Claim form that is sent to the insurance company for review and payment. Divided into sections and blocks that must be filled out correctly. |
| Referrals | Document or form required by insurance companies that is used when a provider wants to send a patient to a specialist. It can be sent manually and electronically. |
| Participating Provider | Means 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 | Total amount owed on an account |
| Debt | 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's favor |
| Assets | The entire sale-able property of a person, association, corporation or estate applicable or subject to the payment of debts |
| Liabilities | Amounts owed; debt |
| Electronic Medical Record (EMR)/Electronic | Allow for charges to be kept in an easy to use computer system that will allow you to post charges, payments, and make adjustments to a patient's account. The systematized collection of patient electronically stored health information in a digital format. |
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