Term
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Definition
| industry term to describe an insurance company that provides coverage for life, health, auto, home or any other type of policy |
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Term
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Definition
| contract between the insurance company and the policy holder that defines the terms or provision of coverage |
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Term
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Definition
| a specified time period usually annually, when subscribers enroll into their health plans |
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Term
| Subscriber,Insured,Policy Holder |
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Definition
| person who holds the insurance |
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Term
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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 |
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Term
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Definition
| general insurance term in reference to anyone who receives benefits,i.e,health, life, disability |
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Term
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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. |
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Term
| Explanation of Benefits (EOB) |
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Definition
| this is sent from the insurance carrier that explains how the claim was handled (paid,denied,pended) |
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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 |
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Term
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Definition
| this insurance company determines what services meet the criteria for consideration of benefits |
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Term
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Definition
| when someone is covered by two or more plan that have similar types of coverage |
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Term
| Coordination of benefits (COB) |
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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. |
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Definition
| to determine whom would cover children - which ever parent month of birthday comes first - if same date - whoever has had insurance the longest |
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Term
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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 |
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Term
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Definition
| is used to describe care in an out patient setting, like the emergency room, urgent care clinics |
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Term
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Definition
| set $ amount that need to be satisfied on a yearly basis in order to receive payments on medical care and services. |
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Term
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Definition
| this is the percentage that eligible charges are paid by the insurance company ( 80 %, 90% ) |
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Term
| Allowable/Eligible/Covered Expense - indemnity |
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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 |
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Term
| Reasonable and Customary ( R and C ) - indemnity |
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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 |
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Term
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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 |
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Term
| out of pocket (OOP) - provision - indemnity |
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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 $ |
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Term
| life time maximums - indemnity |
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Definition
| a set $ amount that once reached, the patient will no longer be able to receive any future compensation (250,000 - 1,000,000) |
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Term
| basic insurance (medicare part A) indemnity |
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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 |
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Term
| major medical insurance ( Medicare part B) indemnity |
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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 |
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Term
| Last quarter carry over (LQCO) indemnity |
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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 |
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Term
| COBRA ( COnsolidated Omnibus Budget Reconciliation Act 1985 ) |
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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 . |
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Term
| individual deductible / Family deductible |
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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 |
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Term
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Definition
| each person in the family can help satisfy the family dedutible. $ put together to help satisfy amount |
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Term
| non-aggregate/non-accumulative |
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Definition
| each person must satisfy a set $ on an individual basis. the $ is NOT pooled w other family members |
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Term
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Definition
| Capitation provider gets paid on # of ppl that sign up w him - whether they see him or not |
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Term
| HMO- health maintance organization |
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Definition
| strick plan-must stay in plan to receive benefits |
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Term
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Definition
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Term
| Non participating Provider |
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Definition
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Term
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Definition
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Term
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Definition
| not accepting new patients |
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Term
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Definition
| flat $ amount - patient portion of visit |
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Term
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Definition
| set $ determined by contract - no recovery and customary (r & c) |
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Term
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Definition
| applied to dr payment ins.co. holds portion of patient bill - if dr does not refer patient out |
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Term
| authorization/referrals drs /scripts |
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Definition
| for okay for insurance company , get approval # goes on insurance form |
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Term
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Definition
| $ amount how much will b covered or paid for |
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Term
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Definition
| whether charge is covered |
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Term
| Medical Case Management ( MCM ) |
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Definition
| Assigns registered nurses to high risk cases |
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Term
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Definition
| Insurance co usually employs nurses to review claims by over utilization |
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Term
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Definition
| work w/ patients re education of contract to dr office |
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Term
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Definition
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Term
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Definition
| the amount of the billed charge the insurance company deems is payable by the plan |
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Term
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Definition
| medical care on an outpatient basis, hospital outpatient, dr visits, er dept |
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Term
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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%) |
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Term
| PPO Preferred Provider Organization Plans |
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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 |
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Term
| Health maintenance Organization Plans (HMOs) |
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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 |
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Term
| POS Point of Service Plans |
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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 |
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