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29 Cards in this Set
- Front
- Back
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Beneficiary |
designated person who receives finds from an insurance policy |
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capitation |
payment arrangement for healthcare providers |
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claim |
a formal request for payment from an insurance company for services provided |
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explaination of benefits (EOB) |
a doc sent by the insurance company to the provider and the patient explaining: 1. the allowed charged amount 2. the amount reimbursed for services 3. the patient's financial responsibilities |
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fee schedule |
a list of fixed fees for services |
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gatekeeper |
the PCP, who is in charge of a patient's treatment. additnl treatment, ex referral to specialist, must be approved by gatekeeper |
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health insurance exchange |
an online marketplace where people can compare and buy individual health insurance plans. state health insurance exchanges were established as part of the ACA. |
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indigent |
poor, needy, impoverished |
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online insurance web portal |
an online service provided by various insurance company that allows providers to look up a patient's: 1. insurance benefits 2. eligibility 3. cliams status 4. explaination of benefits |
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policy |
written agreement between 2 parties one party (ins comp) agrees to pay another party (patient) if certain specified circumstances occur |
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pre-authorization |
a process req by some ins carriers in which health care provider obtains permission to perform certain procedures/services |
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premium |
Amt paid / to be paid by the policyholder for coverage under the contract usually in periodic installments |
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pre-existing condition |
health problem that was present before New health insurance coverage started |
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provider network |
approved list of physicians, hopsitals, and other provider |
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qualified Medicare beneficiaries (OMBs) |
low-income Medicare patient's who qualify for Medicaid for their secondary insurance |
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referral |
order from a PCP for the patient to see a specialist / get certain med services |
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resource-based relative value system (RBRVS) |
system used to determine how much HC providers should be paid for services provided used by Medicare + other health insurance companies |
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3rd party administrator (TPA) |
an org that processes claims and provides administrative services for another org. often used by self-funded plans |
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utilization mngmnt |
decision-making process used by managed care orgs to manage HC costs involved case-by-case assessments of the appropriateness of care |
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waiting period |
length of time and patient waits for a disability insurance to pay after the date of the injury |
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subscriber |
person responsible for payment of the premium cost |
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Cost sharing (definition + name the kinds) |
most policies require patient to pay a portion of the HC expenses. includes: 1. deductible 2. co-insurance 3. Co-payment |
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deductible |
a kind of cost sharing a set dollar amount that the policy holder must pay before the insurance comp starts to pay for services the higher the deductible, the lower the premium |
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if DEDUCTIBLE is HIGH, then the PREMIUM is ______ |
lower |
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co-insurance |
a kind of cost-sharing after deductible has been met, the policy holder may need to pay a cartoon % of bill - insurance comp pays the rest |
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copayment |
set dollar amt policyholder must pay for each office visit can different according to type of care (ex PCP vs specialist vs ER) |
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Name the types of essential health BENEFITS the federal government requires all health plants to cover |
1. ambulatory patient services 2. hospitalization 3. mental health and substance use disorder servcs 4. preventative and wellness services and chronic disease management 5. emergency services 6. maternity and newborn care 7. rehabilitative/habilitative services/devices8. lab services 9. pediatric services (incl oral/vision) |
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name all the types of HEALTH INSURACE PLANS in the US |
1. gvrnment 2. private |
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define + list MEDICALLY NECESSARY services |
medically necessary services = necessary to improve patient's current health 1. alcohol misuse screening 2. blood pressure s.3. cholesterol s.4. colorectal cancer s.5. depression s.6. diabetes type 2 s. 7. diet counseling 8. hep B/C s. 9. HIV s.10. immunization vaccines 11. lung cancer s. 12. obesity s. and counseling 13. tobacco use s. 14. STI prevention counseling |
