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35 Cards in this Set
- Front
- Back
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Required by Medicare when a service is provided to a beneficiary that is either not covered or the provider is unsure of coverage |
Advance beneficiary notice (ABN) |
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Legislation passed in 2010; mandates minimum coverage that must be offered by every health insurer. Requires every American to health insurance, or face fines, tax, and penalties. |
Affordable Care Act (ACA) |
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The maximum amount an insurer will pay for any given service |
Allowed amount |
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The authorization, by signature of the patient, for payment to be made directly by the patients insurance to the provider for services |
Assignment of benefits |
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A form that must be signed by the patient before any information may be given to an insurance company or any other third party |
Authorization to release medical information (release of medical information form) |
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Person entitled to benefits of an insurance policy. This term is most widely used by Medicare |
Beneficiary |
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The health care provider is paid a fixed amount per member per month for each patient who is a member of a particular insurance organization regardless of whether services were paid |
Capitation |
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Term used to refer to insurance companies that reimburse for health care services |
Carrier |
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Individual and family health insurance plans that emphasize coverage for hospitalizations or serious illness ( may be referred to as hospital only or short-term plans) |
Catastrophic Plans |
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Established in 1973 for spouses and children of veterans whi have total, permanent, service- connected disabilities |
Civilian Health and Medical Program of the Development of Veteran Affairs (CHAMPVA) |
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The standard claim form designed by the Center for Medicare and Medicaid to submit providers services for third party (,insurance companies) payment |
CMS-1500 |
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The percentage owed by the patient for service rendered after a deductible has been met and a co-payment has been paid |
Coinsurance |
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Procedures insurers use to avoid duplication of payment on claims when the patient has more than once policy. One insurer become the primary payer, and no more than 100 percent of the costs are covered |
Coordination of benefits |
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A specific amount the insured must pay towards the charge for professional services rendered at the time of service |
Co-payment |
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A predetermined amount the insured must pay each year before the insurance company pay for an accident or illness |
Deductible |
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A prospective payment system developed by Yale university and used by Medicare and other insurers to classify illnesses according to diagnosis and treatment. Greg's group all charges for hospital inpatient services inti a single bundle for payment purposes |
Diagnosis-related group |
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The date the insurance policy goes into effect |
Effective date |
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EPO are like HMO in that patient must use their EPO provider network when receiving care. There is no partial cover for out-of-network care |
Exclusive provider organization (EPO) |
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A printed description of the benefits provided by the insurer to the beneficiary |
Explanation of benefits |
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The action of health care providers informing patents of the amount of charges before the service is performed |
Fee disclosure |
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A list of predetermined payment amounts for professional services provided to patients |
Fee schedules |
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A term given to primary care provider because they are responsible for coordinating the patient care to specialist, hospital admission and so on |
Gatekeeper |
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Insurance offered to all employees by an employer |
Group insurance |
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Group insurance that entitles members to services provided by participating hospitals, clinics, and providers |
Health maintenance organizations (HMO) |
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A type of HMO in which contracted services are provided by providers who main their own offices |
Independent practice association (IPA) |
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Insurance purchased by an individual or family who does not have access to group health insurance |
Individual insurance |
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The maximum amount a non participating provider cab collect for services provided to a Medicare patient |
Limited charge |
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Payment made to an insured person to help replace income lost through inability to work because of an insured disability |
Loss of income benefits |
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A health care delivery system that combines the delivery of health Carr and payment of the service |
Managed Care |
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A joint funding by program by federal and state governments for the medical care of low income patients on public assistance |
Medicaid |
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A federal for providing health Care coverage for individuals over the age of 65 or those who are disabled |
Medicare |
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A list of approved professionals services Medicare will pay for with the maximum fe ot pays fire each service |
Medicare fee schedule |
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Private insurance to supplement Medicare benefits for payment of the deductible, co-payment, and coinsurance. |
Medigap |
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A provider whi has contracted to participate with an insurance company to be reimbursed for services according to the company's plan |
Member provider |
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A nonprofit organization created to improve patient care quality a need health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector |
National committee for quality assurance |
