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55 Cards in this Set
- Front
- Back
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CASE MANAGEMENT:
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A REVIEW OF THE CLINICAL SERVICES BEING PERFORMED
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OUT OF NETWORK PROVIDER:
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NOT CONTRACTED WITH THE HEALTH PLAN
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DEDUCTIBLE:
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THE AMOUNT OF MONEY A PATIENT MUST PAY OUT OF POCKET BEFORE THE INSURANCE COMPANY WILL START TO PAY FOR COVERED BENEFITS
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CO-INSURANCE:
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THE PRE-ESTABLISHED PERCENTAGE OF EXPENSES PAID BY THE INSURANCE COMPANY AFTER THE DEDUCTIBLE IS MET
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CO-PAYMENT:
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A FIXED DOLLAR AMOUNT THAT MUST BE PAID EACH TIME A PATIENT VISITS A PROVIDER
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COORDINATION OF BENEFITS RULES:
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DETERMINE WHICH INSURANCE PLAN IS PRIMARY AND WHICH IS SECONDARY
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BIRTHDAY RULE:
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THE HEALTH PLAN OF THE PARENT WHOSE BIRTHDAY COMES FIRST IN THE CALENDAR (REGARDLESS OF THEIR AGE) IS DESIGNATED AS THE PRIMARY PLAN
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CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)
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INSURANCE PLAN THROUGH A PREVIOUS EMPLOYER
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THIRD PARTY LIABILITY INSURANCE:
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IF AN ACCIDENT HAS OCCURRED, THE THIRD PARTY LIABILITY INSURANCE SHOULD BE FILED AS PRIMARY
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PRIVATE INSURANCE:
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INSURANCE PURCHASED THROUGH AN INSURANCE COMPANY, SUBSIDIZED THROUGH PREMIUMS PAID DIRECTLY TO THE COMPANY
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SELF-INSURANCE:
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INSURANCE THAT IS OBTAINED FROM AN EMPLOYER, THESE PLANS ARE SELF-INSURED BY THE EMPLOYER AND TEND TO BE LOWER BECAUSE ADDITIONAL FEES ARE NOT BUILT INTO THE PREMIUM
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THIRD PARTY PAYER:
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ORGANIZATION OTHER THAN A PATIENT WHO PAYS FOR SERVICES, SUCH AS INSURANCE COMPANIES, MEDICARE, AND MEDICAID
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MEDICARE:
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HEALTH INSURANCE PROVIDED TO PEOPLE AGE 65 OR OLDER, PEOPLE YOUNGER THAN 65 WHO HAVE CERTAIN DISABILITIES, AND PEOPLE WITH END-STAGE KIDNEY DISEASE
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MEDICARE PART A:
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PROVIDES HOSPITALIZATION COVERAGE TO INDIVIDUALS ELIGIBLE FOR THE MEDICARE BENEFIT (GENERALLY FREE OF CHARGE WITH A DEDUCTIBLE)
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MEDICARE PART B:
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VOLUNTARY SUPPLEMENTAL MEDICAL INSURANCE (SMI) TO HELP PAY FOR PHYSICIANS’ AND OTHER MEDICAL PROFESSIONALS’ SERVICES, MEDICAL SERVICES, AND MEDICAL SERVICE SUPPLIES NOT COVERED BY MEDICARE PART A (WITH A DEDUCTIBLE AND 20% COINSURANCE OF MEDICARE’S ALLOWABLE CHARGE FOR MOST SERVICES)
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MEDICARE ADVANTAGE (MA):
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COMBINED PACKAGES OF BENEFITS UNDER MEDICARE PARTS A AND B THAT MAY OFFER EXTRA COVERAGE FOR SERVICES SUCH AS VISION, HEARING, DENTAL, HEALTH AND WELLNESS, OR PRESCRIPTION DRUG COVERAGE
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HEALTH MANAGEMENT ORGANIZATION (HMO’S):
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ALLOWS PATIENTS TO ONLY GO TO PHYSICIANS, OTHER HEALTH CARE PROFESSIONALS, OR HOSPITALS ON THE PLAN’S LIST OF APPROVED PROVIDERS, EXCEPT IN AN EMERGENCY
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PREFERRED PROVIDER ORGANIZATIONS (PPO’S):
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ALLOWS PATIENTS TO USE DOCTORS, SPECIALISTS, AND HOSPITALS IN THE PLANS NETWORK. (GOING TO DOCTORS OR HOSPITAL NOT ON THE LIST USUALLY MEANS THAT PATIENTS WILL HAVE TO PAY EXTRA)
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PRIVATE FEE FOR SERVICE:
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ALLOWS PATIENTS TO GO TO ANY PHYSICIAN, OTHER HEALTH CARE PROFESSIONAL, OR HOSPITAL AS LONG AS THE PROVIDERS AGREE TO TREAT THOSE PATIENTS. THE PLAN DETERMINES HOW MUCH IT WILL PAY PROVIDERS AND HOW MUCH PATIENTS MUST PAY FOR CARE
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MEDICARE SPECIALTY PLANS:
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PROVIDE FOCUSED, SPECIALIZED HEALTH CARE FOR SPECIFIC GROUPS OF PEOPLE SUCH AS THOSE WHO HAVE BOTH MEDICARE AND MEDICAID, LIVE IN A NURSING HOME, OR HAVE CHRONIC MEDICAL CONDITIONS
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MEIDCARE PART D:
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THE DRUG BENEFIT PLAN IS RUN BY PRIVATE INSURANCE COMPANIES AND OTHER VENDORS APPROVED BY MEDICARE
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OUT OF POCKET EXPENSES:
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ARE APPLIED TO INDIVIDUALS WHO ELECT THE TRADITIONAL MEDICARE PART A, B, AND D. PATIENTS ARE RESPONSIBLE FOR CHARGES NOT COVERED BY MEDICARE, AS WELL AS FOR VARIOUS COST SHARING REQUIREMENTS OF PARTS A AND B
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MEDICAID:
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THE GOVERNMENT BASED HEALTH INSURANCE OPTION THAT IS FUNDED THROUGH A PARTNERSHIP BETWEEN THE STATE GOVERNMENTS AND THE FEDERAL MEDICAID PROGRAM. THE PROGRAM PAYS FOR MEDICAL ASSISTANCE FOR INDIVIDUALS WITH LOW INCOME AND LIMITED FINANCIAL RESOURCES
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STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP):
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THIS PROGRAM IS JOINTLY FUNDED BY THE FEDERAL GOVERNMENT AND THE STATES TO PROVIDE HEALTH INSURANCE TO FAMILIES WITH CHILDREN. THE PROGRAM WAS DESIGNED TO COVER UNINSURED CHILDREN IN FAMILIES WITH INCOMES THAT ARE MODEST BUT TOO HIGH TO QUALIFY FOR MEDICAID.
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COMMERCIAL INSURANCE:
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REFERS TO TWO KINDS OF INSURANCE: PRIVATE AND EMPLOYER BASED SELF-INSURANCE
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PRIVATE INSURANCE:
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IS PAID FOR BY THE INDIVIDUAL
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EMPLOYER BASED SELF-INSURANCE:
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IS TIED TO AN INDIVIDUAL’S PLACE OF EMPLOYMENT
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ADMINISTRATIVE SERVICES ONLY (ASO):
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A CONTRACT THAT EMPLOYERS FUND THE PLAN THEMSELVES, AND THE PRIVATE INSURERS ADMINISTER THE PLANS FOR THE EMPLOYER
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BLUE CROSS AND BLUE SHIELD PLANS:
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WERE THE FIRST PREPAID PLANS IN THE U.S. ORIGINALLY, BLUE CROSS (BC) COVERED HOSPITAL CARE AND BLUE SHIELD (BS) COVERED PHYSICIAN SERVICES. BLUE CROSS (BC) MERGED WITH BLUE SHIELD (BS)TO FORM BLUE CROSS AND BLUE SHIELD ASSOCIATION (BC/BS)
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UTILIZATION REVIEW:
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A PROCESS USED TO DETERMINE THE MEDICAL NECESSITY OF A PARTICULAR PROCEDURE OR SERVICE, WAS DESIGNED TO ENSURE THAT THE PROCEDURE OR SERVICE IS APPROPRIATE AND IS BEING PROVIDED IN THE MOST EFFECTIVE WAY
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STAFF MODEL:
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PROVIDES HOSPITALIZATION AND PHYSICIAN SERVICES THROUGH ITS OWN STAFF; PHYSICIANS ARE EMPLOYEES PAID EITHER BY A SALARY OR ON A PREDETERMINED FIXED AMOUNT PER MEMBER PER MONTH AND OWNS ITS OWN FACILITY
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GROUP PRACTICE MODEL:
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CONTRACTS WITH AN OUTSIDE MEDICAL GROUP FOR SERVICE, PROFESSIONALS IS PAID ON A CAPITATION BASIS
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CAPITATION:
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THE FIXED AMOUNT A PROVIDER RECEIVES
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NETWORK MODEL:
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CONTRACTS WITH 2 OR MORE INDEPENDENT PRACTICES
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INDEPENDENT PRACTICE ASSOCIATION (IPA) MODEL:
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CONTRACTS WITH THE IPA ON A CAPITATION BASIS, AND THE IPA IN TURN MAY REIMBURSE THE PHYSICIAN ON A CAPITATED OR A FEE FOR SERVICE BASIS, PARTICIPATING PHYSICIANS SEE PATIENTS THAT ARE PART OF THE HMO AND THOSE WHO ARE NOT.
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REFERRAL:
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WRITTEN RECOMMENDATION TO A SPECIALIST
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GATEKEEPER:
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DETERMINES THE APPROPRIATENESS OF THE HEALTH CARE SERVICES, LEVEL OF HEALTH CARE PROFESSIONAL CALLED FOR AND SETTING FOR CARE
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PREAUTHORIZATION:
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WHEN A HEALTH CARE PLAN IS NOTIFIED THAT A HOSPITAL STAY IS COMING UP, GIVING THE PLAN THE OPPORTUNITY TO DETERMINE IF THE HOSPITAL STAY IS MEDICALLY NECESSARY AND HOW MANY DAYS THE PATIENT WILL MOST LIKELY NEED TO STAY
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PREAUTHORIZATION NUMBER:
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NUMBER GIVEN WHEN HEALTH CARE SERVICES HAS BEEN APPROVED
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PRECERTIFICATION:
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A REVIEW THAT LOOKS AT WHETHER THE PROCEDURE COULD BE PERFORMED SAFELY BUT LESS EXPENSIVELY IN AN OUTPATIENT SETTING
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PREDETERMINATION:
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WRITTEN REQUEST FOR A VERIFICATION OF BENEFITS
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COST SHARING PROVISIONS:
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WHICH HELP DETERMINE HOW MUCH THE INSURANCE WILL PAY AND HOW MUCH THE PATIENTS OWE; USUALLY INVOLVING DEDUCTIBLES, COPAYMENTS, AND THE COINSURANCE PERCENTAGE
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DEDUCTIBLE:
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THE AMOUNT OF MONEY PATIENTS MUST PAY OUT OF POCKET BEFORE THE INSURANCE COMPANY WILL START TO PAY FOR COVERED BENEFITS; MUST BE MET EACH CALENDAR YEAR, AND ANY EXPENSES NOT COVERED WILL BE APPLIED TO THE DEDUCTIBLE
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COPAYMENT:
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A FIXED DOLLAR AMOUNT, OFTEN CALLED A FLAT FEE, WHICH MUST BE PAID EACH TIME A PATIENT VISITS A PROVIDER
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FORMULARY:
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A LIST OF PRESCRIPTION DRUGS COVERED BY THE INSURANCE PLAN
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FORMULARY TIER 1:
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GENERIC (THE LEAST EXPENSIVE DRUG IN THE FORMULARY) OR THOSE NOT COVERED BY A PATENT
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FORMULARY TIER 2:
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NON GENERIC PRESCRIPTION DRUG WITH A PREFERRED BRAND NAME
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FORMULARY TIER 3:
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A PRESCRIPTION DRUG WITH A NON-PREFERRED BRAND NAME
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FORMULARY TIER 4:
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THE DRUG IS NOT ON THE FORMULARY
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MEDICAL SERVICES TIER 1:
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PROVIDERS AND FACILITIES IN A PPO’S NETWORK
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MEDICAL SERVICES TIER 2:
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PROVIDERS AND FACILITIES WITHIN A BROADER, CONTRACTED NETWORK OF THE INSURANCE COMPANY
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MEDICAL SERVICES TIER 3:
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PROVIDERS AND FACILITIES OUT OF THE NETWORK
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MEDICAL SERVICES TIER 4:
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PROVIDERS AND FACILITIES NOT ON THE FORMULARY
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PREFERRED PROVIDER:
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TIER 2 PROVIDER
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COINSURANCE:
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SOMETIMES REFERRED TO AS THE RATE OF PAYMENT, IS THE PRE-ESTABLISHED PERCENTAGE OF EXPENSES PAID BY THE INSURANCE CARRIER AFTER THE DEDUCTIBLE HAS BEEN MET
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