Hit232 - Chapter 3 Key Terms Flashcards

Front 1

This is the amount the provider actually bills a patient, which may differ from the allowable charge.

Back 1

Actual Charge

Front 2

This is the enrollment of excessive proportion of persons with poor health status in a healthcare plan or organization.

Back 2

Adverse Selection

Front 3

The average or maximum amount the third party payer will reimburse providers for the service.

Back 3

Allowable charge

Front 4

This is the healthcare service for which the healthcare insurance company will pay.

Back 4

Benefit

Front 5

The total dollar amount that a healthcare insurance company will pay for covered healthcare services during a specified period of time.

Back 5

Benefit cap

Front 6

The specific amount, in a certain time frame such as one year, beyond which all covered helathcare services for that policyholder or dependent are paid at 100 percent by the insurance plan.

Back 6

Catastrophic expense limit

Front 7

This the member of a group for which the employer or association has purchased group healthcare insurance.

Back 7

Certificate holder

Front 8

This is the request for payment, or itemized statement of healthcare services and their costs provided by a healthcare provider.

Back 8

Claim

Front 9

This is a cost-sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met.

Back 9

Coinsurance

Front 10

This is the method of integrating benfits payments from all health insurance soursces to ensure that payments do not exceed 100 percent of the covered healthcare expenses.

Back 10

Coordination of benefit

Front 11

Cost-sharing measure in which the policy holder pays a fixed dollar amount per service.

Back 11

Copayment

Front 12

The provision of a healthcare insurance policy that requires policy holders to pay for a portion of their healthcare services.

Back 12

Cost-Sharing

Front 13

health condition, illness, injury, disease, or symptom for which the healthcare insurance company will pay.

Back 13

Covered Condition

Front 14

Specific service for which a healthcare insurance company will pay.

Back 14

Covered service

Front 15

Prior health care coverage that is taken into account to determie then allowable length of preexisting condition exclusion periods.

Back 15

Creditable coverage

Front 16

Reduction of waiting period for preexisting condition based on previous creditable coverage.

Back 16

Credited coverage

Front 17

The annual amount of money that the policy holder must incur and pay before the health insurance willl assume liability for the remaining charges.

Back 17

Deductible

Front 18

Medical tests, visits, and procedures to avert or prevent medicl litigation.

Back 18

Defensive medicine

Front 19

The insured's spouse and unmarried children, claimed on income tax.

Back 19

Dependent

Front 20

The language or statements within a healthcare insurance policy providing additional details about coverage or lack of coverage for special situations that are not usually included in standard policies.

Back 20

Endorsement

Front 21

Statement or proof of a health status necessary to obtain healthcare insurance, especially private healthcare insurance.

Back 21

Evidence of insurability

Front 22

Situation, instance, condition, injury, or treatment that the healthcare plan states will not be covered .

Back 22

Exclusion

Front 23

Report sent from ahealthcare insurer to the policyholder and to the provider that describes the healthcare service, its cost, and the amount the healthcare insurer will cover.

Back 23

Explanation of benefits

Front 24

The list of preferred drugs including brand-name and generic

Back 24

Formulary

Front 25

The person who is responsible for paying the bill or guarantees payment for healthcare services.

Back 25

Guarantor

Front 26

Traditional, fee-for-service healthcare plan in which the policyholder pays a monthly premium and a percentage of the usual, customary, and reasonable healthcare costs.

Back 26

Indemnity health insurance

Front 27

Individual or entity that purchases healthcare coverage.

Back 27

Insured

Front 28

Individual who doe snot enroll in a group healthcare plan at the first opportunity, but enrolls later if the plan has a general open enrollment period.

Back 28

Late enrollee

Front 29

Qualification or other specification that reduces or restricts the extent of the healthcare benefit.

Back 29

Limitation

Front 30

The specific amount ina certain timeframe such as one year, beyond which all covered healthcare services for that policyholder are paid 100 percent by the insurance plan.

Back 30

Maximum out-of-pocket cost

Front 31

Severe injury or illness

Back 31

Medical emergency

Front 32

Healthcare services and supplies that are proven or acknowledged to be effective in the diagnosis, treatment, cure, reliefof symptoms and to be consistent with the communities standard of care.

Back 32

Medical necessity

Front 33

The individual or entitiy that purchases helathcare insurance coverage.

Back 33

Member

Front 34

ny change in behavior that occurs a s a result of becoming insured.

Back 34

Moral hazard

Front 35

The payment made by the policyholder or member.

Back 35

Out-of-pocket

Front 36

The binding contract issued by a healthcare insurance comapny to an individual or group in which the company promises to pay for healthcare to treat illness or injury.

Back 36

Policy

Front 37

The individual or entity that purchases healthcare insurance coverage.

Back 37

Policyholder

Front 38

The process of obtaining approval from a healthcare insurance company before receiving healthcare services.

Back 38

Precertification

Front 39

Disease, illness, ailment, or other condition for which within six months before the insured's enrollment date of coverage, medical advice, diagnosis, care, or treatment was provided.

Back 39

Pre-existing condition

Front 40

The amount of money that policyholder or certificate holder must periodically pay a healthcare insurance plan in return for coverage.

Back 40

Premiums

Front 41

The entitiy responsible for the greatest portion or majority of the healthcare expense.

Back 41

Primary insurer

Front 42

The process of obtianing approval from a healthcare insurance company prior to receiving services.

Back 42

Prior Approval

Front 43

This si a document added to a healthcare policy that provides details about coverage or lack of coverage for special situations.

Back 43

Rider

Front 44

The group of people who wil lbe covered by a healthcare insurance plan.

Back 44

Risk pool

Front 45

Entity responsible for the remainder of the healthcare expenses after the primary insurer.

Back 45

Secondary insurer

Front 46

Specific amount beyond which all covered healthcare services for that policyholder or dependent are paid 100 percent by the healthcare plan.

Back 46

Stop-loss benefit

Front 47

The individual or entity that purchases healthcare insurance coverage.

Back 47

Subscriber

Front 48

Additional healthcareinsurancethat fills in the gaps in comprehensive insurance or Medicare benefits.

Back 48

Supplemental insurance

Front 49

The process of identifying and classifying individuals' or groups' risk.

Back 49

Underwritting

Front 50

Tyoe of retrospective fee-for-service payment method in which the third party payer pays for fees that are UCR.

Back 50

Usual, Customary, And reasonable (UCR)

Front 51

Time between the effective date of a healthcare insurance policy and the date the healthcare insurance plan will assume liability for expenses related to certain health services.

Back 51

Waiting period