General Terminology
What does CAQH stand for?
Council for Affordable Quality Healthcare
A fixed out of pocket amount payed by the insured for covered services such as doctor visit or prescription medication
Co-pay
The health care services covered by your health plan, which is the type of coverage you pick
Benefits, Plan, or Explanation of Benefits
Managed Care Organization is a health care company. It is often called a "health plan." It is a group of doctors, hospitals and other providers who work together to meet your health care needs.
Federal law that prevents group health plans from imposing less favorable benefit limitations on mental health and substance use benefits
Mental Health Parity
Need to register for in order to bill insurance
NPI (National Provider Identification number)
How much you pay for insurance, typically broken down into a monthly dollar amount
Premium
How long your benefits are good for
Benefit Year
Four Medicaid Managed Care Organizations
Molina, CareSource, UHC Community, Buckeye Health
MOPS fee for 60 min Individual Psychotherapy session
$150
Billing service codes (length and type)
How much you have to pay before your health plan starts to pay its portion of the bill
Deductible
A list of providers that your plan contracts
In-Network
Providers for Medicare
Social Worker or Psychologist (under the license of either)
In order to have sliding scale funding you must do what
supplement with grant funding or donations/foundation money to make up the balance
Diagnosis codes
ICD
The maximum amount that you will have to pay out of pocket for covered services in a plan year
Out of Pocket Limit
Determination that a treatment or service is medically necessary, must occur prior to the service is provided (ie. psychological testing, extended length of services)
Prior Authorization
Qualification for Medicaid
ABD and Income
Four specific layers of health insurance billing
Group of medical professionals and groups who come together voluntarily to give coordinated high-quality care to their patients. The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. Credentials and negotiations unit rates. Succeeds both in delivering high-quality care and spending health care dollars more wisely, share in the savings with the program.
Accountable Care Organization (ACO), MOPS participates in an ACO with Partners for Kids
The difference between the allowed amount and what your provider charges (what you owe)
Balance Billing
What your health insurance provider will not cover under your health plan (cosmetic, unnecessary services)
Excluded Services
Top for commercial insurances MOPS contracted with
Medical Mutual of Ohio, Aetna, Anthem, United HealthCare
Difference between FSA and HD/HSA
Flexible spending accounts (FSA) and High Deductible/Health Savings Accounts (HSA) is that an individual controls an HSA and allows contributions to roll over, while FSAs are less flexible and are owned by an employer. This means that if you left your job, the funds in your FSA may be forfeited while any funds in your HSA are yours to keep (and rollover into another HSA account). Both FSAs and HSAs allow people to save for their medical expenses on a tax-advantaged basis by using pretax money to pay for qualified medical costs.