Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
38 Cards in this Set
- Front
- Back
|
Benefits
|
The amount of money a health plan pays for services covered in an insurance policy
|
|
|
Capitation
|
Payment method in which a prepayment covers the provider's services to a plan member for a specified period of time
|
|
|
Coinsurance
|
The portion of charges that an insured person must pay for health care services after payment of the deductible amount; usually stated as a percentage
|
|
|
Consumer-driven health plan (CDHP)
|
Type of medical insurance that combines a high-deductible health plan with a medical savings plan that covers some out-of-pocket expenses
|
|
|
Copayment
|
An amount that a health plan requires a beneficiary to pay at the time of service for each health care encounter
|
|
|
Covered services
|
Medical procedures and treatments that are included as benefits under an insured's health plan
|
|
|
Deductible
|
An amount that an insured person must pay, usually on an annual basis, for health care services before a health plan's payment begins
|
|
|
Ethics
|
Standards of conduct based on moral principles
|
|
|
Etiquette
|
Standards of professional behavior
|
|
|
Excluded services
|
A service specified in a medical insurance contract as not covered
|
|
|
Fee-for-service
|
Method of charging under which a provider's payment is based on each service performed
|
|
|
Health care claim
|
An electronic transaction or a paper document filed with a health plan to receive benefits
|
|
|
Health Maintenance Organization (HMO)
|
A managed health care system in which providers agree to offer health care to the organization's members for fixed periodic payments from the plan; usually members must receive medical services only from the plan's providers
|
|
|
Health plan
|
Under HIPAA, an individual or group plan that either provides or pays for the cost of medical care; includes group health plans, health insurance issuers, health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other government and nongovernment plans
|
|
|
Indemnity plan
|
Type of medical insurance that reimburses a policyholder for medical services under the terms of its schedule of benefits
|
|
|
Managed care
|
System that combines the financing and the delivery of appropriate, cost-effective health care services to its members
|
|
|
Managed care organization (MCO)
|
Organization offering some type of managed health care plan
|
|
|
Medical insurance
|
Financial plan that covers the cost of hospital and medical care.
|
|
|
Medical insurance specialist
|
Medical office administrative staff member who handles billing, checks insurance, and processes payments
|
|
|
Medical necessity
|
Payment criterion of payers that requires medical treatments to be appropriate and provided in accordance with generally accepted standards of medical practice. To be medically necessary, the reported procedure or service must match the diagnosis, be provided at the appropriate level, not be elective, not be experimental, and not be performed for the convenience of the patient or the patient's family
|
|
|
Network
|
A group of providers having participation agreements with a health plan. Using in-network providers is less expensive for the plan's enrollees
|
|
|
Noncovered services
|
Medical procedures that are not included in a plan's benefits
|
|
|
Open-access plans
|
Type of health maintenance organization in which a member can visit any specialist in the plan's network without a referral
|
|
|
Out-of-network
|
A provider that does not have a participation agreement with a plan. Using out-of-network providers is more expensive for the plan's enrollees
|
|
|
Out-of-pocket
|
Expenses the insured must pay before benefits begin
|
|
|
Payer
|
Health plan or program
|
|
|
Point-of-service (POS) option
|
In HMO's plan that permits patients to receive medical services from non network providers; this choice requires a larger patient payment than visits with network providers
|
|
|
Policyholder
|
Person who buys an insurance plan; the insured, subscriber, or guarantor
|
|
|
Preauthorization
|
Prior authorization from a payer for services to be provided; if preauthorization is not received, the charge is usually not covered
|
|
|
Preexisting condition
|
Illness or disorder of a beneficiary that existed before the effective date of insurance coverage
|
|
|
Preferred provider organization (PPO)
|
Managed care organization structured as a network of health care providers who agree to perform services for plan members at discounted fees; usually, plan members can receive services from non-network providers for a higher charge
|
|
|
Premium
|
Money the insured pays to a health plan for a health care policy
|
|
|
Preventive medical services
|
Care that is provided to keep patients healthy or to prevent illness, such as routine checkups and screening tests
|
|
|
Primary care physician (PCP)`
|
A physician in a health maintenance organization who directs all aspects of a patient's care, including routine services, referrals to specialists within the system, and supervision of hospital admissions; also known as a gatekeeper
|
|
|
Provider
|
Person or entity that supplies medical or health services and bills for or is paid for the services in the normal course of business. Examples would be: physician, facility, skilled nursing home, or the hospital
|
|
|
Referral
|
Transfer of a patient from one physician to another
|
|
|
Schedule of benefits
|
List of medical expenses that a health plan covers
|
|
|
Third party payer
|
Private or government organization that insures or pays for health care on the behalf of beneficiaries; the insured is first party, the provider is 2nd party, and the payer is the 3rd party
|
