Term
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Definition
| Pulling out information from a health record. |
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Term
| ACII (American Standard Code for Information Interchange) |
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Definition
| The most common format used for text files in computers and on the Internet. |
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Term
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Definition
| Authorization to send reimbursement check directly to the health care provider. |
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Definition
| A person who receives benefits through Medicare. |
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Term
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Definition
| A company that receives claims from health care providers and specializes in consolidating the claims so that they can send one transmission to each third-pary payer. |
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Term
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Definition
| Claims that can be processed for payment quickly without being returned due to errors or omissions. |
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Term
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Definition
| Universal form used to submit insurance claims. |
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Term
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Definition
| Information such as name, address, Social Security number, and employment. |
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Term
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Definition
| Multipurpose billing form. |
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Term
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Definition
| Font in which each character takes up exactly the same amount of space. |
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Term
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Definition
| Red ink used on a CMS-1500 form so the red ink "disappears" after it is scanned so the computer only reads what is written on the form. |
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Term
| optical character recognition (OCR) |
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Definition
| The recognition of printed or written text characters by a computer. |
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Term
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Definition
| Form used to keep track of patient charges and payments. |
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Term
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Definition
| Form that is signed by a patient that allows you to |
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Term
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Definition
| Provider of services w/less than 25 full-time employees or a physican/facility/supplier w/ less than 10 full time employees. |
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Term
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Definition
| A provider is told in writing that he or she does not have to comply with a certain regulation. |
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Term
| administrative services orgaization (ASO) |
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Definition
| Provides a wide variety of health insurance administrative services for organizations that have chosen to self-fund their health benefits. |
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Term
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Definition
| Freedom to choose what medical expenses will be covered. |
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Term
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Definition
| Insurance that covers hospital inpatient care/room and board, Some hospital services/ supplies, Surgery, Physician visits. |
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Term
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Definition
| Links independent BCBS plans so that members and their families can obtain health care services while traveling or working anywhere in the U.S. |
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Term
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Definition
| Provides BCBS plan members inpatient and outpatient coverage at no additional cost in more than 200 foreign countries. |
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Term
| Blue Cross and Blue Shield Federal Employee Program (FEP) |
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Definition
| Enrolls several million federal government employees, retirees, and their dependents. |
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Term
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Definition
| Eliminating a certain specialty of health services from coverage under the the health care policy. |
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Term
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Definition
| Percentage of health care expenses. |
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Term
| commercial health insurance |
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Definition
| Any kind of health insurance paid for by someone other than the government. |
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Term
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Definition
| A combination of basic health insurance and major medical insurance. |
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Term
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Definition
| Charges incurred that qualify for reimbursement under the terms of the policy contract. |
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Term
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Definition
| Out-of-pocket payment before the health insurance carrier begins to contribute. |
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Term
| Employee Retirement Income Security Act of 1974 (ERISA) |
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Definition
| Sets minimum standards for pension plans in private industry. |
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Term
| explanation of benefits (EOB) |
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Definition
| A document prepared by an insurance carrier that gives details of how the claim was adjudicated. |
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Term
| Federal Employees health Benefits (FEHB) |
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Definition
| A government health insurance plan for its own civilian employees. |
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Term
| fee-for-service (FFS)/indemnity plan |
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Definition
| Traditional type of health care policy where the insurance company pays fees for the services provided to persons covered under the policy. |
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Term
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Definition
| Processor of Medicare claims. |
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Term
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Definition
| A contract between an insurance company and an employer that covers eligible employees or members. |
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Term
| health insurance policy premium |
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Definition
| A periodic payment which allows you to be covered under an insurance policy. |
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Term
| health maintenance organization (HMO) |
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Definition
| A plan that provides health care to its enrollees from specific doctors and hospitals that contract with the plan. |
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Term
| health care service plans |
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Definition
| Provide health care coverage through BCBS. |
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Term
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Definition
| Limits the amount of money the policyholder has to pay our-of-pocket for any one incident or in any one year. |
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Term
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Definition
| An amount after which the insurance company would not pay any more of the charges incurred. |
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Term
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Definition
| Insurance that covers treatment for long, high-cost illness/injury; inpatient/outpatient expenses. |
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Term
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Definition
| The financing, managing, and delivery of health care services and comprises a group of providers who share the financial risk of the plan. |
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Term
| Medicare supplement plans |
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Definition
| Designed specifically to provide coverage for some of the costs that Meicare does not pay. |
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Term
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Definition
| An amount of money in a pension plan employees do not have to give up when quitting or retiring. |
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Term
| participating provider (PAR) |
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Definition
| A provider who participates through a contractual arrangement with a health care service contractor. |
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Term
| point-of-service (POS) plan |
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Definition
| A hybrid of managed care and traditional indemnity under which the insured can choose whether to use a network or a non-network provider. |
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Term
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Definition
| The individual in whose name the insurance policy is written. |
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Term
| preferred provider organization (PPO) |
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Definition
| A network of health care providers that have agreed to provide medical services to a health plan's members at discounted costs. |
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Term
| reasonable and customary fee |
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Definition
| Commonly charged or prevailing fees for health services within a geographic area. |
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Term
| self-insured/self-insurance |
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Definition
| The employer, not an insurance company, is responsible for the cost of medical services. |
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Term
| single or specialty service plans |
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Definition
| Health plans that provide services only in certain health specialties. |
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Term
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Definition
| Protection from the devastatinh effect of exorbitant medical claims. |
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Term
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Definition
| Add-on coverage to insurance plans. Ex: Vision, dental, RX. |
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Term
| third-pary administrator (TPA) |
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Definition
| A person or organization who processes claims and performs other contractual administrative services. |
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Term
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Definition
| Any organization that provides payment for specified coverages provided under the health plan. |
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Term
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Definition
| A reimbursement system in which health care providers receive a fixed fee for every patient enrolled in the plan, regardless of how many or few services the patient uses. |
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Term
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Definition
| Other health care providers in the community generally cannot participate. |
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Term
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Definition
| When a PCP sends a patient to another health care provider for the purpose of the consulting physician rendering his or her expert opinion regarding the patient's condition. |
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Term
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Definition
| A small fixed amount required by a health insurer to be paid by the insured for each outpatient visit or drug prescription. |
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Term
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Definition
| Similar to an IPA except the HMO contracts directly with the individual physicians. |
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Term
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Definition
| A health care plan member. |
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Term
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Definition
| A written complaint submitted by an individual covered by the plan. |
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Term
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Definition
| HMO contracts with independent, multispecialty physician groups who provide all health care services to its member. |
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Term
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Definition
| A symptom or illness brought on unintentionally by something that a physician does or says. |
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Term
| individual practice association (IPA) |
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Definition
| Services are provided by outpatient networks composed of individual health care providers who provide all the needed health care services for the HMO |
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Term
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Definition
| An interrelated system of people and facilities that communicate with one another and work together as a unit. |
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Term
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Definition
| HMO has multiple provider arrangements, including staff, group, or IPA structures. |
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Term
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Definition
| Other health care providers in the community may participate, if they meet certain HMO/IPA standards. |
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Term
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Definition
| A procedure required by most managed health care and indemnity plans before a provider carries out specific procedures or treatments for a patient. |
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Term
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Definition
| A process used by health insurance companies to control health care costs and is similar to pre-authorization. |
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Term
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Definition
| When the provider notifies the insurance company of the recommended treatment before it begins. |
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Term
| primary care physician (PCP) |
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Definition
| A specific provider who oversees the member's total health care treatment. |
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Term
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Definition
| A request by a health care provider for a patient under his or her care to be evaluated or treated by another provider, usually a specialist. |
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Term
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Definition
| A physician who is trained in a certain area of medicine. |
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Term
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Definition
| A multispecialty group group practice in which all health care services are provided within the buildings owned by the HMO. |
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Term
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Definition
| A system designed to determine the medical necessity and appropriateness of a requested medical service, procedure, or hospital admission. |
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