Insurance Terms
The person whose name the insurance is carried under is called the ________.
Subscriber
Eligibility for Medicaid is ________.
based on the patient's reported income and assets from the previous month
MCO
Managed Care Organization
When the MA confirms with the insurance company that the patient has coverage for a procedure before scheduling, the process is called ________blank
Precertification
A(n) "________" healthcare claim is one that is error-free and is accepted for processing by the payer
clean
The fixed dollar amount a subscriber must pay or "meet" each year before the insurer begins to cover expenses is the ________.
Deductible
_________ is a health cost assistance program, NOT an insurance program.
Medicaid
PPO
Preferred Provider Organization
Insurance carriers perform a review for medical ________ on each claim to determine whether the treatment is needed for the diagnosis listed.
Necessity
A claims ______ is a list or spreadsheet that contains information about every claim submitted by the office.
register
When the insured person pays an annual cost for healthcare insurance, it is called a ________.
Premium
When a provider agrees to accept assignment for a Medicare patient, this means the provider ________.
will accept the amount of money Medicare pays as payment in full
GAF
Geographic Adjustment Factor
Some payers offer an Internet-based service called ________ ________ _______, or ______ , that allows medical offices to enter data without EDI formatting.
Direct Data Entry, or DDE
Offices whose medical billing software vendors do not have translation software must use a ________ in order to send and receive data in the correct EDI format.
clearinghouse
Expenses that are not covered by an insurance plan are called _______.
Exclusions
Because Medicare pays 80% of approved charges and the patient is responsible for the remaining 20%, individuals enrolled in the Original Medicare Part B plan often buy additional insurance called a(n) ________plan.
Medigap
ABN
Advance Beneficiary Notice of Noncoverage
The electronic claim transaction preferred by Medicare is the X12 837 Health Care Claim, commonly referred to as the "________ claim.
HIPAA
The oldest and most expensive type of healthcare plans repay policyholders for costs of healthcare due to illness and accidents and are called ________ plans.
Fee-for-service (or indemnity)
Under a contracted or fixed prepayment called ________, providers are paid a fixed amount of money to provide needed care.
Capitation
Which Medicare plan covers prescription medications?
Part D
RBRVS
resourced-base relative value scale
The payment system used by ________blank is called the RBRVS.
Medicare
An RBRVS fee has three parts and uses the formula _________ x ________ x _________.
RVU, GAF, CF