Chapter 19 Vocabulary List
Terms
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- Individual Policy
- An insurance policy designed specifically for the use of one person not association with the amenities of a group policy, namely higher premiums.
- birthday Rule
- Under law, the rule stating that when an individual is covered under two insurance policies, the insurance plan of the policyholder whose birthday come first in the calender year becomes the primary insurance.
- Commercial Insurance
- Plans that reimburse the insured for expenses resulting from illness or injusry according to a spefic fee schedule as outline in the insurance policy and on a fee-for-service basis.
- Dependents
- The spouse, children, and sometimes domestisc partners or other individuals designed by the insured who are covered under a healthcare plan.
- Health Insurance
- Protaction in returne for periodic premium payments that provid reimbursments of exspenses resulting from illness or injury.
- Primary Care Provider
- A general practice, or non specialist provider or physician responible for the care of a patient for some heath maintance organization.
- Carriers
- As related to insurance, companies that assume the risk of an insurance policy.
- Co-insurance
- A policy provision frequently found in medical insurance whereby the policyholder and the insurance company share the cost of covered losses in a specific ratio.
- Beneficiary
- Individual entitled to recieve benifits from an insurance policy or program or a governmental entitlement program offering healthcare benifits
- Medicare
- A federally sponsored heath insurance program for those who are 65 or individuals inder 65 but disabled.
- Policyholder
- A person who pays a premuim to an insuracne company and in whose name the policy is written in exchange for the insurance protection provided by a policy of insurance.
- Self-Insured plan
- An insurance plan funded by an organization having a large enough employee base taht it can afford to fund its own insurance program.
- Resource-based relative value scale
- A fee schedule designed to provide national iniform payment of Medicare benfits after being adjusted to reflect the differences in practice costs across geographic areas.
- Worers comp
- Insurance against liability imposed on certain employers to pay benifits and furnish care to employeess killed in the course of or arising out of their employment.
- Explantion of benefits
- A letter or statement from the insurace carrier describing what was paid, denied, or reduced in payment.
- Medical Savings Accounts
- Tax-deferred bank or saving accounts that are combined with a low premium, high deductable insurance policy, designed for indicidual or families who choose to fund their own heathcare expenses and medical insurance.
- Preauthorization
- A process required by some insurance carriers where the provider obtains permission to perform certain procedures or serivces, or refer a patient to a specailist.
- Eligibility
- A term which desribes whether a patients insurance coverage is in effect so that benifts are payable.
- Effective date
- The date on which an insurance policy or plan takes effect so that benefits are payable.
- Medigap
- A term sometimes applied to private insurance products taht supplement Medicare insurance benifits.
- Captiation
- Payment method used by many managed care organization wherein a fixed amount of money is reimbersed to the provider for patient enrolled during a specific period of time, no matter what services were recieved or how many visits were made.
- Insured
- An individual or organization covered be an insurance policy according to the policy terms, usually the individual or group taht pays the premiums.
- Exclusion
- Limitations on an insurance contract for which benefits are not payable,.
- Third-Party Payor
- Entities that make payment on an obligation or debt but are not parties of the contract that created the debt.
- Rider
- A special provision or group of provisions that may be added to a policy to expand or limit the benifits otherwise payable.
- Premium
- The periodic payment of a specific sum of money to an insurance company for which the insurer, in return, agrees to provide certain benifits
- Fiscal Intermediary
- An organization that contracts with the govenment to handle and mediate insurance claims from medical facilities, home health agencies, or providers of medical services or supplies.
- Disabilitiy Income insurance
- Insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease.
- fee for service
- An established schedule of fees set for services performed by providers and paid by the patient.
- Self-Refered
- The act of a patient or insured individual who refers himself orherself to a specialist without requesting the referral from the primary provider.
- Service benifit plan
- Plans that provide benifits in the form of certain surgical and medical cervices rendered, rather than a cash.
- Guarantor
- The person whi is responsible for paying a medical bill
- Benifits
- The amount payable by an insurance company for a monetrary loss to an indiviual insured by that company, under each coverage.
- TRICARE
- A government sponsored program wherein authorized dependents of military personal recieve medical care
- Authorization
- A term used in managed care for an approved referal
- Participating Porvider
- A physician or other heathcare provider who enters into a contract with a specific insurance company or program, and by doing so agree to abide by certain rules and regulations set forth by that particular third- party payor.
- Third party Administator
- An organizartion that processes claims and performs other business related functions for a heath plan.
- Government plans
- Entitlment programs or healthcare plans that are sponsered and/ or subsidized by the state or federal government, such as Medicaid or medicare.
- Heath Maintance Organization HMO
- Sn organization that provides a wide range of comprhensive heathcare srevices for a specified group at a fixed periodic payment.
- Uilization review
- A review of individual cases by a committee to make sure that services are medically necessary and to study how proivders use medical care resources.
- Allowed charge
- The maximum amount of money that many third-party payors allow for a specific procedure or service.
- CHAMPVA
- A health benifits program run by the Department of Veterans Affairs that help eligible beneficiaries pay the cost of specific healthcare services and supplies.
- Group policy
- Insurance written under a policy taht covers a nukber of people under a single master contract issued to their employer or to an association with which they are affiliated.
- Copayment
- A sum of money that is paid at the time of medical service
- Deductibles
- Specific amounts of money a patient must pay out of pocket before the insurance carrier begins paying.
- Managed care plans
- An umbrella term for all heathcare plans that provide heathcare in return for preset monthly payments and coordinated care through a define network of primary care physicians and hospitals
- Medicaid
- A federal and state sponsered heath insurance program for the medically indigent.
- HIPPA
- The kassebaum-Kennedy Act designed to improve portability and continuity of heath insurance coverage
- Referral
- An insurance term used when a primary care provider wnat to send a patient to a specialist.
- Remittance Advice
- An explanation of benifits which comes from Medicaid.
- Indemnity Policy
- Traditional heath insuracne planes that pay for all or share of the cost of covered services, regardless of which physician, hospital, or other licensed heathcare provider is used.
- CHAMPUS
- A government-sponsered program wherein authorized dependents of milatary personal recieve medical care.