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;
31 Cards in this Set
- Front
- Back
|
To make healthcare work by improving the health are experience for our members and the communities we serve.
|
Mission
|
|
|
Employers who provide healthcare coverage to their employees as part of their benefits.
|
Groups
|
|
|
A person other than the subscriber who is covered under the policy.
|
Dependents
|
|
|
To be the best health plan, both locally and nationally, by helping our members become and stay healthy.
|
Vision
|
|
|
The maximum dollar amount determined to be appropriate reimbursement by Horizon.
|
Allowed Amount
|
|
|
A numerical classification that describes disease, injuries and causes of death.
|
Diagnoses Code
|
|
|
The Medicare component that provides benefits to cover the costs pf physicians’ professional services.
|
Medicare Part B
|
|
|
The Medicare component that provides benefits to cover the costs pf physicians’ professional services.
|
MEDICARE PART B
|
|
|
A healthcare option that allows members to choose at the time medical services are needed whether they will go to a provider within the plan’s network or seek medical care outside the network.
|
POS
|
|
|
The standard form used by professional healthcare providers to submit claims.
|
CMS1500
|
|
|
Hospice
|
A facility or service that provides care for terminally ill patients and support to their families. Emphasis is on symptom control and emotional support.
|
|
|
Fee-for-Service
|
A method of charging whereby a provider bills and/or submits a claim for each service rendered or supply provided with the expectation of payment.
|
|
|
Maximum Benefit Limit
|
Maximum amount paid for a member’s particular benefit. The amount varies depending on the type of plan and the specific benefit.
|
|
|
Medically Necessary
|
Services or supplies which are determined to be appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition and provided for the diagnosis and/or treatment of the medical condition.
|
|
|
Preventive Care
|
Proactive health care designed to keep people from getting sick or hurt. It includes but it not limited to immunizations and screenings.
|
|
|
EPO
|
A type of PPO program where members must receive services from an in-network provider only. There are no benefits for non-participating providers except for medical emergencies.
|
|
|
Deductible
|
The amount of eligible expenses that must be incurred by the member before Horizon assumes any liability for all or part of the remaining cost of covered services.
|
|
|
Co-insurance
|
A method of cost-sharing in health insurance policy that requires a group member to pay a stated percentage of all remaining eligible medical expenses after the deductible amount has been paid.
|
|
|
Coordination of Benefits (COB)
|
It means of dividing the responsibility of providing benefits for covered services among two or more carriers or plans. The combined payments may pay up to, but not exceed, 100% of billed charges for covered services.
|
|
|
Co-payment
|
A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered
|
|
|
Claim
|
An itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other provider facility.
|
|
|
Explanation of Benefits (EOB)
|
A form sent to members, after a claims has been processed explaining how benefits were adjudicated.
|
|
|
Out-of-Pocket Costs/Expenses
|
Costs such as co-payments, coinsurance and deductibles that must be paid by an insured individual out of the own money.
|
|
|
Out-of-Pocket Maximum
|
The maximum amount set by a plan that a member has to pay out of his /her own pocket for particular healthcare services during a particular time period.
|
|
|
Referral
|
A written recommendation on our form by a physician and/or health plan for a member to receive care from a Horizon participating specialist provider.
|
|
|
Lifetime Maximum
|
Maximum amount that a health insurance policy will pay in a member’s lifetime. The amount varies depending on the type of coverage and the plan.
|
|
|
Facility Coverage
|
Covers services rendered by as hospital or other facility.
|
|
|
Professional Coverage
|
Covers services rendered by a physician.
|
|
|
Supplemental Coverage
|
Covers other services not eligible under either Facility or Professional.
|
|
|
Medical Review
|
Process by which claims and or medical records are evaluated by Registered Nurses and or Doctors for medical necessity, appropriateness of care and/or reimbursement.
|
|
|
Insured
|
A person who is covered for insurance under an insurance policy.
|
