Medical Assistant Health Insurance Terms

crossover claim

A claim that is processed by Medicare then "crossed over" to Medicaid to pay toward the co-insurance and deductible. If the claim doesn't "cross over" automatically from Medicare, it can be submitted to the payer by the provider.

birthday rule

A method of determining which parent's medical coverage will be primary for dependent children, the birthday month that is first is the primary (year doesn't effect it).

capitation

A payment method for health care services. The physician, hospital, or other health care provider is paid a contracted rate for each member assigned, referred to as "per-member-per-month" rate, regardless of the number or nature of services provided. The contractual rates are usually adjusted for age, gender, illness, and regional differences.

beneficiary

A person(s) other than the member of an insurance or pension plan who has been designated to receive benefits under an insurance policy or plan, Medicare or Medicaid programs

primary care physician (PCP)

A physician, such as a family practitioner or internist who is chosen by an individual to provide continuous medical care, trained to treat a wide variety of health-related problems, and responsible for referral to specialists as needed.

claim

A statement listing services rendered, the dates of services, and itemization of costs. Includes a statement signed by the beneficiary and treating professional that services have been rendered. The completed form serves as the basis for payment of benefit.

explanation of benefits (EOB)

A statement provided by the payor or insurance company that explains the medical services provided, the allowable reimbursement amounts, any deductibles, coinsurance or other adjustments taken and the net amount paid.

health maintenance organization (HMO)

A type of group health care practice that provides basic and supplemental health maintenance and treatment services to voluntary enrollees who prepay a fixed periodic fee that is set without regard to the amount or kind of services received.

medical savings account

Accounts in which tax-deferred deposits can be made for medical expenses.

government plan

Entitlement programs, healthcare plans, sponsored and subsidized by the government.

carrier

Health plans: insurance company, payer third party.

medically indigent

In the health care system of the United States, these are persons who do not have health insurance and who are not eligible for other health care coverage, such as Medicaid, Medicare, or private health insurance. Those who are "medically indigent earn too much to qualify for Medicaid but too little to purchase either health insurance or health care."

co-payment

Managed Care-That portion of a claim or medical expense that a health plan member must pay out-of-pocket for specific medical services-eg, hospital care, drugs, office visits, etc; the insurer pays the remaining portion.

coinsurance

Portion of charges that insured must pay for health care services after payment of deductible.

eligibility

Qualified to participate, determination that a patient's insurance coverage is in effect and that they are eligible for insurance benefits

fee-for-service

Referring to the traditional form of reimbursement for health care services, where a fee is paid to a provider, according to the service performed, by a Pt or a conventional indemnity insurer, after a service is rendered.

proof of eligibility (POE)

The act of confirming that a patient has insurance coverage.

deductible

The amount of a medical expense for which the beneficiary is responsible before a third party will assume any liability for payment of benefits.It may be an annual or one-time charge and may vary in amount from program to program.

balance-billing

The billing of a patient for the difference between the professional's actual charge and the amount reimbursed under the patient's benefits plan (illegal)

Health Care Financing Administration (HCFA) now (CMS)

The branch of the U.S. Department of Health and Human Services responsible for administering the Medicare and Medicaid programs. HCFA sets the coverage policy, payment, and other guidelines and directs the activities of government contractors (e.g., carriers and fiscal intermediaries).

usual, customary and reasonable (UCR)

The fee that an individual professional most frequently charges for a given service. Plus the fee level determined by the administrator of a benefits plan from actual submitted fees for a specific procedure to establish the maximum benefit payable under a given plan for that specific procedure. Plus a fee is considered reasonable if, in the opinion of a responsible review committee.

allowed charge

The maximum dollar amount that a third party, usually an insurance company, will reimburse a provider for a specific service.

waiting period

Time period between date of enrollment and date insurance coverage is in effect.

coordination of benefits (COB)

Used when one plan and another group plan provides coverage for the same allowable expense incurred by a claimant. An allowable expense will be covered in part by at least one of the plans. The provision has been implemented to prevent a "profit" situation.

assignment of benefits

an arrangement by which a patient (beneficiary) requests (authorizes) that their health benefit payments be made directly to a designated person or facility (treating professional).

health insurance portability and accountability act (HIPAA)

An act of Congress, passed in 1996, that affords certain protections to persons covered by health care plans, including continuity of coverage when changing jobs, standards for electronic health care transactions, and privacy safeguards for individually identifiable patient information.

preferred provider organization (PPO)

An organization of physicians, hospitals, and pharmacists whose members discount their health care services to subscriber patients. It may be organized by a group of physicians, an outside entrepreneur, an insurance company, or a company with a self-insurance plan.

pre-existing conditions

Any injury, disease, or disability that may have occurred at some time in the past and may predispose an individual to limited health in the future.

workers compensation

Payments required by law to be made to an employee who is injured or disabled in connection with work.

dependent

Person other than insured covered by a health care plan. (spouse, child). Relying on or requiring the aid of another for support.