Chapter 27 Matching Insurance

Front 1

Specific amount that the insured must pay toward the charge for professional services rendered at the time of service

Back 1

Co payments

Front 2

Predetermined amount that the insured must pay each year before the insurance company will pay for an accident or illness

Back 2

Deductible

Front 3

Insurance offered to all employees by the employer

Back 3

Group insurance

Front 4

Procedures used by insurers to avoid duplication of payment on claims when a patient had more than one policy

Back 4

Coordination of benefits

Front 5

Group insurance that entitles members to services provided by participating hospitals, clinics, and providers

Back 5

Health maintenance organizations (HMO)

Front 6

Date when an insurance policy goes into effect

Back 6

Effective date

Front 7

When health care providers is paid a fixed amount per member per month for each patient who is a member of a particular insurance organization, whether or not services were provided

Back 7

Capitation

Front 8

Established for the spouse and dependents children of veterans who have total, permanent, service-connected disabilities

Back 8

CHAMPVA

Front 9

Authorization, by signature of the patient, for payment to be paid directly by the patients insurance to the provider for services

Back 9

Assignment of benefits

Front 10

Established to aid dependents of active service personnel, retired service personnel and their dependents, and dependents of service personnel who died on active duty, with a supplement for medical care in military or Public Health Services facilities

Back 10

Tricare

Front 11

Condition that existed before the insured policy was issued

Back 11

Preexisting condition

Front 12

Geographic area served by an insurance carrier

Back 12

Service area

Front 13

Insurance purchased by an individual or family who does not have access to group health insurance

Back 13

Individual insurance

Front 14

Method of controlling health care costs by reviewing services to be provided to members of a plan to determine the appropriate and medical necessity of the care prior to the delivery of the care

Back 14

Utilization management (review)

Front 15

Health delivery system that combines the delivery of health care and payment of the service

Back 15

Managed care

Front 16

Joint funding program by federal and state governments for the medical care of low-income patients on public assistance

Back 16

Medicaid

Front 17

A form of insurance providing wage replacement and medical benefits to employees who are injured on the job or who have developed work related disorders, disability, or illness

Back 17

Workers compensation

Front 18

Approval obtained before the patient is admitted to the hospital or receives specific outpatient or in-office procedures

Back 18

Precertification

Front 19

Person who is insured; an insurance policyholder

Back 19

Subscriber

Front 20

Commercial plan in which the insurance company or group reimburses providers or beneficiaries for services

Back 20

Indemnity plan

Front 21

For payment of other medical expenses, including offices visits, Xray and laboratory services, and the services of a provider in or out of the hospital

Back 21

PART B

Front 22

Also known as Medicare Advantage

Back 22

PART C

Front 23

Enables beneficiaries to select a managed care plan as their primary coverage

Back 23

PART A

Front 24

For hospital coverage

Back 24

PART A

Front 25

A benefit that was introduced for beneficiaries as of January 1, 2005, was the Initial Preventive Physical Exam, otherwise known as the Welcome to Medicare visit

Back 25

PART B

Front 26

Provide coverage for both generic and brand name drug

Back 26

PART D

Front 27

Referred to as a cafeteria plan

Back 27

Flexible spending arrangement

Front 28

The plan is usually funded by the employee with pretax dollars

Back 28

Flexible spending arrangement

Front 29

A "use it or lose it" type of plan

Back 29

Flexible spending arrangement

Front 30

An employer can contribute, but an employee cannot

Back 30

Health reimbursement arrangement

Front 31

A tax sheltered savings account that can be used to pay for medical expenses

Back 31

Health savings account

Front 32

The employer owns the money in this account, and it might not be portable when the employee leaves the company

Back 32

Health reimbursement arrangements

Front 33

Any amount not used in a given year remains in the account and continue to gain interest

Back 33

Health savings account

Front 34

The amount can be rolled over from one year to the next

Back 34

Health reimbursement arrangements

Front 35

Has a high deductible and must be paired with a qualified health plan

Back 35

Health savings account

Front 36

Preventive care is not subject to the deductible

Back 36

Health savings account

Front 37

Numeric values assigned to payment components of the resource based relative value scale (RBRVS)

Back 37

relative value units

Front 38

Provider who has contracted with an insurer and accepts whatever the insurance pays as payment in full

Back 38

Participating provider

Front 39

Term for an insurance company that reimburse for health care services

Back 39

Carrier

Front 40

Procedures used by insurers to avoid duplication of payment on claims when the patient has more than one policy

Back 40

Coordination of benefits

Front 41

Payment made to an insured person to help replace income lost through inability to work because of an insured disability

Back 41

Loss of income benefits

Front 42

When health care providers inform patients of charges before the services are performed

Back 42

Fee disclosure

Front 43

Insurance company that intervenes to pay hospital or medical per contract with the doctor or patient

Back 43

Third party payer

Front 44

Required by Medicare when services is provided to a beneficiary who is either not covered or the provider is unsure of coverage

Back 44

Advance beneficiary notice

Front 45

List of predetermined payment amounts for professional services provided to patients

Back 45

Fee schedules

Front 46

Patient eligibility for benefits

Back 46

Patient status

Front 47

Refers to obtaining plans approval for services prior to the patient receiving them

Back 47

Predetermination

Front 48

Refers to the discovery of maximum amount of money the carrier will pay for primary surgery, consultation services, postoperative care, and so on

Back 48

Predetermination

Front 49

Seeking approval for a treatment ( surgery,hospitalizations, diagnostic tests) under patient insurance contracts

Back 49

Precertification

Front 50

Relates not only to whether the service are covered but also whether the proposed treatment is medically necessary

Back 50

Preauthorization