Insurance Vocab

Perform ___________ and ___________ coding and review the encounter form or charge ticket for completeness after the patient is seen by the provider.

Diagnostic and procedural

___________ ___________ ___________ provides periodic payments to replace income when an insured person in unable to work as a result of illness, injury, or disease.

Disability income insurance

The ___________ ___________ is the date on which an insurance policy or plan takes effect so that benefits are payable.

Effective date

___________ is a term that indicates whether a patient's insurance coverage is in effect and the patient is eligible for payment of insurance benefits.

Eligibility

Verify the patient's ___________ for insurance payment with the insurance carrier or carriers as well as ___________ available, exclusions, and whether ___________ ___________ are needed to refer patients to specialists or to perform certain services or procedures, suck as surgery or diagnostic tests.

Eligibility, benefits, special authorizations

The term for limitations on an insurance contract for which benefits are not payable is ___________ .

Exclusions

An ___________ ___________ ___________ is a letter or statement from the insurance carrier that describes what was paid, denied, or reduced in payment. it also contains information about amounts applied to the deductible, the patient's coinsurance, and the allowed amounts.

Explanation of Benefits

An ___________ ___________ ___________ ___________ is a letter or statement from Medicare that describes what was paid, denied, or reduced in payment. It also contains information about amounts applied to the deductible, the patient's coinsurance, and the allowed amounts.

Explanation of Medicare benefits

An established schedule of fees set for services performed by providers and paid by the patient is called ___________ ___________ ___________ .

Fee for service

___________ ___________ on any rejected or unpaid claims. Ask the insurance carrier for more information about specific claims.

Follow up

The ___________ is the person responsible for paying a medical bill.

Guarantor

The Kassebaum-Kennedy Act, which was designed to improve portability and continuity of health insurance coverage; to combat waste, fraud, and abuse in health insurance and healthcare delivery; to promote the use of medical savings accounts; to improve access to long-term care services and coverage; to simplify the administration of health insurance; and to serve other purposes, is also called the ___________ ___________ ___________ ___________ ___________ ___________ .

Health Insurance Portability and Accountability Act

A ___________ ___________ ___________ is an organization the provides a wide range of comprehensive healthcare services for a specified group at a fixed periodic payment.

Health maintenance organization

___________ ___________ pay for all or a share of the cost of covered services, regardless of which physician, hospital, or other licensed healthcare provider is used. Policyholders of these plans and their dependents choose when and where to get health care services.

Indemnity plans

An ___________ ___________ is designed specifically for the use of one person and is not associated with the amenities of a group policy.

Individual Policy

An umbrella term for all healthcare plans that provide healthcare services in return for preset monthly payments an coordinated care through a defined network of primary care physicians and hospitals in ___________ ___________ ___________ .

Managed care plans

Make adjustments to the account of the allowable amount, which is either written off or passed on to the patient for ___________ .

Payment

The person who pays a premium to an insurance company and in whose name the policy is written in exchange for the insurance protection provided by a policy of insurance is the ___________ .

Policyholder

Obtain ___________ for referral of the patient to a specialist or for special services or procedures that require advance permission.

Preauthorization

___________ is a process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services or to refer a patient to a specialist.

Preauthorization

The periodic payment of a specific sum of money to an insurance company for which the insurer, in return, agrees to provide certain benefits is called a ___________ .

Premium

The ___________ ___________ ___________ is a general practice or nonspecialist provider or physician responsible for the care of a patient for some health maintenance organizations; also called a gatekeeper.

Primary Care Provider

An insurance term used when a primary care provider wants to send a patient to a specialist is ___________ .

Referral

Complete an insurance claim form and submit it to the insurance company for ___________ for services and procedures performed.

Reimbursement

An explanation of benefits that comes from Medicaid is called ___________ ___________ .

Remittance advice

The fee schedule designed to provide national uniform payment of Medicare benefits after adjustment to reflect the differences in practice costs across geographic areas is called the ___________ -___________ ___________ ___________ ___________ .

Resource-based relative value scale

Post payments and adjustments on the patient ledger or account and examine the ___________ ___________ ___________ , ___________ ___________ ___________ ___________ , or ___________ ___________ from the insurance company to identify what was paid, reduced, or denied and the deductible, coinsurance, and allowable amounts.

explanation of benefits, explanation of Medicare benefits, remittance advice

The individual or organization covered by an insurance policy according to the policy terms, usually the individual or group that pays the premiums, is called the ___________ .

insured

Adhere to the ___________ ___________ requirements for each insurance carrier to prevent zero payments from the insurance company and inability to bill the patient.

Timely filing

The government-sponsored program under which authorized dependents of military personnel receive medical care originally was called CHAMPUS but now is called ___________ .

Tricare

A ___________ ___________ is a review of individual cases y a committee to ensure services are medically necessary and to study how providers use medical care resources.

Utilization review

___________ ___________ is insurance against liability imposed on employers to cover medical expenses and lost wages to employees who are injured on the jo and to pay benefits to dependents of employees killed in the course of or arising out of their employment.

Workers' Compensation

An individual entitled to receive benefits from an insurance policy or program or from a government entitlement program offering healthcare benefits is considered the ___________ .

Beneficiary

The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage, is known as ___________ .

Benefits

The ___________ ___________ states that when an individual is covered under two insurance policies, the insurance plan of the policyholder whose birthday comes first in the calendar year becomes the primary insurance.

Birthday rule

___________ is a payment method used by many managed care organizations in which a fixed amount of money is reimbursed to the provider for patients enrolled during a specific time period, no matter what services were received or how many visits were made.

Capitation

In the insurance business, companies that assume the risk of an insurance policy are considered the ___________ .

Carriers

CHAMPUS is the acronym for ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ .

Civilian Health and Medical Program of the Uniformed Services.

The health benefits program run by the Department of Veterans Affairs that helps eligible beneficiaries pay the cost of specific healthcare services and supplies is the ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ .

Civilian Health and Medical Program of the Veterans Administration.

A ___________ -___________ is the sum of money paid at the time of medical service; it is a form of coinsurance

Co-payment

A ___________ provision frequently is found in medical insurance policies whereby the policyholder and the insurance company share the cost of covered losses is a specified ratio.

Coinsurance

___________ ___________ or ___________ ___________ reimburses the insured for expenses resulting from illness or injury according to a specific fee schedule as outlined in the insurance policy and on a fee-for-service basis.

Commercial Insurance, private insurance

Typically met on a yearly or per-incident basis, this specific amount of money, a ___________ , is what a patient must pay out of pocket before the insurance carrier begins paying.

Deductible

Calculate insurance ___________ and coinsurance amounts and provide the patient with a statement showing the ___________ expense, or the amount owed by the patient.

Deductibles, out-of-pocket

Obtain information from the patient and insured, including ___________ , employment, and ___________ data.

Demographic, insurance

___________ are the spouse, children, and sometimes domestic partner or other individuals designated by the insured who are covered under a healthcare plan.

Dependents

___________ ___________ is the maximum amount of money many third-party payers allow for a specific procedure or service.

Allowed charge

An alphanumeric number issued by the insurance company giving approval of a procedure or service is an ___________ .

Authorization

___________ - A federal and state sponsored health insurance program for medically indigent individuals.

Medicaid

___________ - A federally sponsored health insurance program for people older than 65 years or people younger that 65 years who are disabled.

Medicare

___________ - A term sometimes applied to private insurance products that supplement Medicare insurance benefits.

Medigap

Bill the patient for any ___________ ___________ or, if there is a secondary insurance, complete the secondary insurance claim form and submit it to the insurance company with a copy of the EOB showing payment from the primary insurance company.

Outstanding balance

A ___________ ___________ is a physician or other healthcare provider who enters into a contract with a specific insurance company or program and by doin so agrees to abide y certain rules and regulations set forth by that particular third-party payer.

Participating provider