Chapter 7 Medisoft Vocab
capitation
A fixed amount that is paid to a provider to provide medically necessary services to patients.
preferred provider organization PPO
A network of healthcare providers who agree to provide services to plan members at a discounted fee.
point-of-service plan POS
A plan, combining features of an HMO and a PPO, in which members may choose from providers in a primary or secondary network.
copayment
A small fee paid by the patient at the time of an office visit.
managed care
A type of insurance in which the carrier is responsible for the financing and delivery of healthcare.
high-deductible health plan with savings option HDHP/SO
A type of managed care insurance in which a high-deductible plan is combined with a pretax savings account to cover out-of-pocket medical expenses.
health maintenance organization HMO
A type of managed care system in which providers are paid fixed rates at regular intervals.
indemnity plan
An insurance plan in which policyholders are reimbursed for healthcare costs.
clean claims
Healthcare claims with all the correct information necessary for payer processing.
medical necessity
Healthcare services that are reasonable, necessary, and /or appropriate, based on evidence-based clinical standards of care.
coinsurance
Percentage of charges that an insured person must pay for healthcare services after payment of the deductible amount.
payer
Private or government organization that insures or pays for healthcare.
deductible
The amount a policyholder must spend on medical services before benefits begin.
X12 837 Health Care Claim or Equivalent Encounter Information 837P
The electronic format of the claim used by physician offices to bill for services.
CMS-1500
The mandated paper insurance claim form.
