MA Chapter 23 & 26
beneficiary:
A designated person who receives funds from an insurance policy.
explanation of benefits (EOB)
A document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, and the patient's financial responsibilities.
claim:
A formal request for payment from an insurance company for services provided.
Capitation
A payment arrangement for healthcare providers. The provider is paid a set amount for each enrolled person assigned to him or her, per period of time, whether or not that person has received services.
audit:
A process completed before claims submission in which claims are examined for accuracy and completeness. capitation: A payment arrangement for healthcare providers. The provider is paid a set amount for each enrolled person assigned to him or her, per period of time, whether or not that person has received services.
preauthorization
A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services.
Deductible:
A set dollar amount that the policyholder must pay before the insurance company starts to pay for services
Copayment:
A set dollar amount that the policyholder must pay for each office visit. It is possible that copayments differ for different types of office visits.
resource-based relative value system (RBRVS)
A system used to determine how much providers should be paid for services rendered. It is used by Medicare and many other health insurance companies.
policy:
A written agreement between two parties, in which one party (the insurance company) agrees to pay another party (the patient) if certain specified circumstances occur.
Co-insurance:
After the deductible has been met, the policyholder may need to pay a certain percentage of the bill and the insurance company pays the rest
provider network
An approved list of physicians, hospitals, and other providers.
National Provider Identifier (NPI):
An identifier assigned by the Centers for Medicare and Medicaid Services (CMS) that classifies the healthcare provider by license and medical specialties.
health insurance exchange
An online marketplace where you can compare and buy individual health insurance plans.
referral:
An order from a primary care provider for the patient to see a specialist or to get certain medical services
claims clearinghouse:
An organization that accepts the claim data from the provider, reformats the data to meet the specifications outlined by the insurance plan, and submits the claim.
third-party administrato
An organization that processes claims and provides administrative services for another organization. Often used by self-funded plans.
Medicare part A
Inpatient hospital care,
eligibility:
Meeting the stipulated requirements to participate in the healthcare plan.
indigent:
Poor, needy, impoverished
medical necessity
Services or supplies (CPT and HCPCS codes) that are used to treat the patient's diagnosis (ICD codes) meet the accepted standard of medical practice.
waiting period:
The length of time a patient waits for disability insurance to pay after the date of injury.
gatekeeper
The primary care provider, who is in charge of a patient's treatment.
precertification
The process of determining if a procedure or service is covered by the insurance plan and what the reimbursement is for that procedure or service.
CMS-1500 Health Insurance Claim Form
The standard insurance claim form used for all government and most commercial insurance companies.
adjudicate
To settle or determine judicially.
Fee schedule
a list of fixed fees for services