Kinn's MOP Chapter 16 (Basics of Health Insurance

____________________________provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or didease

Disability Insurance

Medicaid and Medicare are examples of ________________ plans

Government sponsered health insurance

A ____________________ is a healthcare plan that controls the cost of healthcare delivery by requiring all patients to seek care with a primary care provider to assess if more specialized care is needed

HMO

_______________________is a third party system that reimburses a provider when services are rendered for an insured patient

Health Insurance

_______________ 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 healthcare services.

Indemnity Plans

A ___________________ is health insurance coverage for those who are not covered by their employer group plan.

Individual health Insurance

Low and middle-income Americans can purchase health insurance at a______________ to apply for health insurance and not worry avout being denied for a pre-existing condition

Insurance Marketplace

An umbrella term for all healthcare plans that focus o reducing the cost of delivering quality care to patient members in return for scheduled payments and coordinated care through a defined network of primary care physicians and hospitals is

Managed care Organization

A_________________is a healthcare provider who enters into a contract with a specific insurance company or program and agrees to accept the contracted fee schedule

Participating provider

The _________________ was passed in 2010 to assist more Americans in obtaining health insurance.

Patient protection and Affordable Care Act

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

Preauthorization

Health insurance companies that operate for profit and use managed care plans to reduce the costs of healthcare

Privately sponsored health insurance

Low-income Medicare patients who qualify for medicaid for the secondary insurance

Qualifies Medical beneficiaries

A ____________________ is funded by an organization with am employee vase large enough to enable it to fund its own insurance program.

employer self funded plan

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

exclusions

A reimbursement model in which the health plan pays the provider's fee for every health insurance claim is called

fee for service

A reimbursement model in which the health plan pays the providers fee for every insurance claim

fee for service

When a provider agrees to become a PAR, they also agree to the health insurance plan's

fee schedule

The primary care provider who can approve or deny when a patient seeks additional care is referred to as a

gatekeeper

A privately sponsored health plan purchased by an employer for their employees is considered a______________policy

group

Health insurance plans pay for health services deemed

medically necessary

Patients have a higher financial responsibility when they access care that is

out of pocket

Healthcare providers need to apply to become a ___________ through a process called credentialing.

participating provider

The intermediary and administrator who coordinates patients and providers as well as processes claims for self-funded plans

Third party administrator

A _________________ is a review of individual cases by a committee to make sure services are medically necessary and to study how providers use medical care resources

Utilization review

____________________________ is the process of confirming health insurance coverage for the patient for the medical service and the date of service

Verification of elifibility

_______________ is an insurance plan for individuals who are injured on the job either by accident or an acquired illness.

Workers Compensation

The _______________ is the maximum that third-party payers will pay for a procedure or service.

allowable charge

Benefits cover the ______________, or the amount that should be paid to the healthcare provider for services rendered.

amount loss

A recipient of health insurance benefits.

beneficiary

The intermediary and administrator who coordinates patients and providers and processes claims for self-funded plans is called a

third party administator

A process of managing healthcare costs by influencing patient care decision making through case by case assessments of the appropriateness of care

utilization management

In the United States, healthcare practitioners render services __________________ receiving payment.

Before

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 health benefits program run by the Department of Veterans Affairs that helps eligible beneficiaries pay the cost of specific healthcare services and supplies in the (give acronym)

CHAMPVA

There are resources for patients who have questions on health insurance coverage through the Patient Protection and Affordable Care Act, such as

Affordable Care Act Navigators Program

A alphanumeric number issued by the insurance company giving approval of a procedure or service is

Authorization Code

________________ are used by many healthcare facility offices to quickly verify eligibility and benefits.

Online insurance provider web portals

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

TRICARE

Active duty military personnel family members of active duty personnel, military retirees and their eligible family members under the age of 65, and the survivors of all uniformed services are covered by

TRICARE

Obtain information from the patient and/or the guarantor, including_______ and_______ data

demographic and Insurance

The ______________________ is the date on which insurance coverage begins so that benefits are payable.

effective date

Verify the patients_______________ for insurance payment with the insurance carrier or carriers. as well as insurance_______, exclusions, and whether__________is required to refer patients to specialists or to perform certain services or procedures. such as surgery or diagnostic tests.

eligibility, benefits, preauthorization

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

preauthorization

The payment of a specific sum of money to an insurance company for a list of health insurance benefits is called a

premium

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

referral

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

resource-based relative value scale

The person who is the signer on the health insurance policy

subscriber