Shared Flashcard Set

Details

Health Insurance
Health Insurance
51
Health Care
Not Applicable
04/29/2011

Additional Health Care Flashcards

 


 

Cards

Term
Carrier
Definition
industry term to describe an insurance company that provides coverage for life, health, auto, home or any other type of policy
Term
Policy
Definition
contract between the insurance company and the policy holder that defines the terms or provision of coverage
Term
open enrollment
Definition
a specified time period usually annually, when subscribers enroll into their health plans
Term
Subscriber,Insured,Policy Holder
Definition
person who holds the insurance
Term
dependents
Definition
anyone in the household that is covered by the insured, this could be a spouse, child, or anyone else that is claim on your income tax as dependent
Term
Beneficiary
Definition
general insurance term in reference to anyone who receives benefits,i.e,health, life, disability
Term
Claim
Definition
a medical form that is filed with a carrier(insurance co) to receive compensation fro patient care. A cms-1500 is used in medical billing, it will include patient name , insurance information, charge and diagnosis info.
Term
Explanation of Benefits (EOB)
Definition
this is sent from the insurance carrier that explains how the claim was handled (paid,denied,pended)
Term
full time student
Definition
this allows dependents to be coverd by the insured passed the standard age of 18. It allows dependents from ages 18-25 to be covered as long as they are enrolled in full time school
Term
medical necessity
Definition
this insurance company determines what services meet the criteria for consideration of benefits
Term
duplication of benefits
Definition
when someone is covered by two or more plan that have similar types of coverage
Term
Coordination of benefits (COB)
Definition
This allows the coordination of two or more plans to carve out benefits against each other. Deciding which plan is payable first, second and so on if needed.
Term
Birthday rule
Definition
to determine whom would cover children - which ever parent month of birthday comes first - if same date - whoever has had insurance the longest
Term
in patient
Definition
this term is used to describe a patient that is admitted into a hospital, or someone who has a stay longer than 18 hrs regardless of whether they have a room
Term
ambulatory / out patient
Definition
is used to describe care in an out patient setting, like the emergency room, urgent care clinics
Term
deductible - Indemnity
Definition
set $ amount that need to be satisfied on a yearly basis in order to receive payments on medical care and services.
Term
co insurance - indemnity
Definition
this is the percentage that eligible charges are paid by the insurance company ( 80 %, 90% )
Term
Allowable/Eligible/Covered Expense - indemnity
Definition
this is the final $ amount deemed payable by the insurance company, after it has determined what is non-covered, above reasonable and customary , or fee schedule
Term
Reasonable and Customary ( R and C ) - indemnity
Definition
this $ amount is determined based on 3 factors drs zip code, cpt code, and date of service.Fee determined within reasonable amounts that other providers are charging for same service in same location and same year
Term
peer review - indemnity
Definition
claims that are over the reasonable and customary amount or over the fee schedule can be sent to a peer review committee to determine correct liability
Term
out of pocket (OOP) - provision - indemnity
Definition
a set $ amount that must be meet by the patient which can include the deductibale and the patients co -insurance amount. Once $ amount satisfied, all furtue claims with in the calendar year will be paid at a higher co insurance rate 80%to 90% - 90% to 100% - does not include non covered $- insured does not get credit for non covered $
Term
life time maximums - indemnity
Definition
a set $ amount that once reached, the patient will no longer be able to receive any future compensation (250,000 - 1,000,000)
Term
basic insurance (medicare part A) indemnity
Definition
is coverage fro all in - in patient hospital services, and they're corresponding charges, usually paid at 100% after any in-patient deductibles and up to a maximum of either $ amounts, or days of stay
Term
major medical insurance ( Medicare part B) indemnity
Definition
this is coverage for all medical services, NOT included in the hospitalization coverage, (drs,labs,etc) that are usually paid at 80% NOT TAKEN PLACE IN HOSPITAL SETTING
Term
Last quarter carry over (LQCO) indemnity
Definition
this is a provision that allows any deductible money taken in the last quarter of calendar year (oct, nov, dec) to be carried over into the next year the help satisfy the deductible
Term
COBRA ( COnsolidated Omnibus Budget Reconciliation Act 1985 )
Definition
employee laid off work from a company that has more than 20 employees. The group health plan must be offered to that employee so they may continue coverage at their own expense .
Term
individual deductible / Family deductible
Definition
each person must satisfy a set $ amount before any charges can be considered, family as a group must satisfy set amount - this can be done 2 different ways-see aggrerate /accumulative
Term
aggregate/accumulative
Definition
each person in the family can help satisfy the family dedutible. $ put together to help satisfy amount
Term
non-aggregate/non-accumulative
Definition
each person must satisfy a set $ on an individual basis. the $ is NOT pooled w other family members
Term
Capitation
Definition
Capitation provider gets paid on # of ppl that sign up w him - whether they see him or not
Term
HMO- health maintance organization
Definition
strick plan-must stay in plan to receive benefits
Term
PCP
Definition
Participating provider
Term
Non participating Provider
Definition
not participating
Term
open panel
Definition
accepting new patients
Term
closed panel
Definition
not accepting new patients
Term
co payment
Definition
flat $ amount - patient portion of visit
Term
Contract / fee schedule
Definition
set $ determined by contract - no recovery and customary (r & c)
Term
withhold
Definition
applied to dr payment ins.co. holds portion of patient bill - if dr does not refer patient out
Term
authorization/referrals drs /scripts
Definition
for okay for insurance company , get approval # goes on insurance form
Term
predetermination
Definition
$ amount how much will b covered or paid for
Term
Precertification
Definition
whether charge is covered
Term
Medical Case Management ( MCM )
Definition
Assigns registered nurses to high risk cases
Term
Utilization Review
Definition
Insurance co usually employs nurses to review claims by over utilization
Term
Provider Relation
Definition
work w/ patients re education of contract to dr office
Term
write off
Definition
dr off
Term
Allowed amount
Definition
the amount of the billed charge the insurance company deems is payable by the plan
Term
ambulatory care
Definition
medical care on an outpatient basis, hospital outpatient, dr visits, er dept
Term
Indemnity plan
Definition
allows you to go to any primary care dr, specialist , hospital that you choose. You or your employer pays the monthly premium. Also have a deductible(500-1000) that u must pay b4 coverage from ur insurance co. begins. After deductible met, ur health plan pays 4 a % of ur healthcare expense(usually 80%)
Term
PPO Preferred Provider Organization Plans
Definition
in this type of managed care plan, providers(hospitals,drs,and other healthcare practioners) agree to provide services at negotiated fees. U r allowed @ go @ out of network providers, but u recieve greater benefits if u stay within the network.Ex. plan may pay 80% in network out of network would pay 60% - generally u have direct access specialist but there r some PPO plans that require a referral
Term
Health maintenance Organization Plans (HMOs)
Definition
contains cost by focusing on prevention and primary care.In general medical care is coordinated and supervised by ur PCP - who must authorize access to specialist. U pay small co payfor each visit or service instead of a deductible and coinsurance. Coverage limited outside the HMO serv. area unless it is an emergency situation
Term
POS Point of Service Plans
Definition
combine hmo and ppo plans. You can choose how you access the plan each time you need treatment. If you choose to use the HMO network, your PCP coordinates care, and your out of pocket cost are minimal. If you choose to go outside the HMO network for care, you may select your physican, but you will have to pay deductible and coinsurance coverage
Supporting users have an ad free experience!