Insurance, billing and coding
Indemnity plan
A commercial plan in which the company (insurance) or group reimburses providers or beneficiaries for services; allows subscribers more flexibility in obtaining services.
Preexisting condition
A condition that existed before the insured's policy was issued.
Member provider
A provider who has contracted to participate with an insurance company to be reimbursed for services according to the company's plan.
Participating provider
A provider who has contracted with an insurer and accepts whatever the insurance pays as payment in full.
Nonparticipating provider
A provider who is not contracted with an insurer and can collect total charges for services provided.
Copayment
A specified amount the insured must pay toward the charge for professional services rendered at the time of service.
Relative Value Units
Numeric values assigned to payment components of the Resource-Based Relative Value Scale (RBRVS).
Point-of-service (POS) plan
An open-ended HMO, which delivers health care services using both a managed care network and traditional indemnity coverage.
Premium
Monies paid for an insurance contract.
Out-of-area
The term used to identify services HMO members receive outside of their specified geographical area.
Medicare
A federal program for providing health care coverage for individuals over the age of 65 or those who are disabled.
Managed care
A health care delivery system that combines the delivery of health care and payment of the services.
Medicaid
A joint funding program by federal and state governments (excluding Arizona) for the medical care of low-income patients on public assistance.
Medicare fee schedule
A list of approved professional services Medicare will pay for with the maximum fee it pays for each service.
Fee schedule
A list of predetermined payment amounts for professional services provided to patients.
Preferred provider organization (PPO)
A network of providers and hospitals that are joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers and their families for a discounted fee.
National Committee for Quality Assurance (NCQA)
A nonprofi t organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector.
Explanation of benefits
A printed description of the benefits provided by the insurer to the beneficiary.
DRG Diagnosis - related group
A prospective payment system developed by Yale University and used by medicare and other insurers to classify illnesses according to diagnosis and treatment.
Gatekeeper
A term given to primary care providers because they are responsible for coordination the patient's care to specialists, hospital admissions, and so on.
IPA Independent practice association
A type of HMO in which contracted services are provided by providers who maintain their own offices.
Precertification
Approval obtained before the patient is admitted to the hospital or receives specifi ed outpatient or in-offi ce procedures.
Resource-based relative value scale (RBRVS)
Fee schedule based on relative value units assigned for resources providers use to provide services for patients: provider work, practice expense, malpractice expense.
Health maintenance organization
Group insurance that entitles members to services provided by participation hospitals, clinics, and providers.
Patient status
Refers to a patient's eligibility for benefits; the basis upon which benefits are being provided (i.e., inpatient, outpatient, ER, office, and so on).
Group insurance
Insurance offered to all employees by an employer.
Individual insurance
Insurance purchased by an individual or family who does not have access to group health insurance.
Limiting charge
Insurance purchased by an individual or family who does not have access to group health insurance.
Loss-of-income benefits
Payments made to an insured person to help replace income lost through inability to work because of an insured disability.
Coinsurance
Percentage owed by the patient for services rendered after deductible.
Medigap (Medifill)
Private insurance to supplement Medicare benefi ts for payment of the deductible, copayment, and coinsurance.
Fee disclosure
The action of health care providers informing patients of charges before the services are performed.
Effective date
The date when the insurance policy goes into effect.
COB Coordination of benefits
procedures insurers use to avoid duplication of payment on claims when the patient has more than one policy. When insurance companies work together so they don't both pay the bill.
