Plan related
A provider who does not sign a contract to participate in a health plan and who refuses to accept insurance allowable as payment in full.
+200 points
OON/ Non-par
Is the person who is/will receive medical treatment. Is also referred to as a member
Patient
Generally, a legal spouse or child who meet eligibility requirements of the policy
Dependent
What is HMO?
Health Maintenance Organization
A twelve-month period that begins on January 1 and ends twelve consecutive months later on December 31
Calendar Year
A physician who is trained in general medical care and treats routine problems. Members have them as their regular doctors/physicians.
+100 points
Primary Care physician (PCP)
Are required when your prescription gets low. Some prescriptions don't come with this because your prescriber may feel you only need a certain amount to feel better.
+100 points
Refills
A fixed amount per contractual period that a patient pays before health insurance will begin to pay; this is only paid if provider services are obtained
○ Amount represented in dollar amount ($).
+200 points
Deductible
This means that a healthcare provider has a contract with a health insurance plan to provide services at a lower rate to the plan members.
+100 points
INN/PAR
It is defined as health professionals who provide healthcare services.
Providers
Is a U.S. Federal-State matching entitlement program that pays for medical assistance for needy individuals and families with low incomes and resources.
+200 points
Medicaid
What is PPO?
+100 points
Preferred Provider Organization
This part of Medicare covers Prescription Drugs or RX
+100 points
Part D
A physician who has more advanced medical training than a primary care physician and is certified to practice in a specific field. They treat complicated medical conditions in his specific area of training and is generally more expensive than a primary care doctor.
+100 points
Specialty Care / Specialists
Often abbreviated as Rx, is a formal communication from a physician or other registered healthcare professional to a pharmacist. It authorizes the pharmacist to dispense a specific prescription drug for a specific patient
+200 points
Prescription
○ A small, fixed amount a patient directly pays a provider for specific services.
○ Amount represented in dollar amount ($).
Copayment
When the same type of commercial plan is collectively purchased by a group of people. Is usually purchased by employers for their employees.
+100 points
Group insurance
Is the organization that has contracted with a patient to pay for a patient’s healthcare services. Referred to as “Insurance Companies.”
+100 points
Payors
Is a U.S. federal government program, which pays for certain healthcare services.
It is the US’s largest health insurance program which originated from the federal law, Title XVIII of the Social Security Act.
+200 points
Medicare
HMO-POS
+100 points
Point of Service
This part of Medicare covers Hospital Insurance.
Part A
In the U.S. this a place other than a hospital that performs outpatient surgery.
In here (in and out) surgery center, you may stay for only a few hours, or for one night (less than 24 hours.)
+200 points
Ambulatory Surgical Center
These are prescription drugs that has the same active-ingredient formula as a brand name drug. Usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
+100 points
Generic drug
○ A fixed percentage a patient pays for services received after a deductible and/or applicable copayment have been paid; the insurance company pays the remaining percentage.
○ Amount tepresented in percent (%).
Coinsurance
When a commercial insurance is purchased by an individual. People who are self-employed would purchase this type of policy.
Individual insurance
A written and/or verbal request from a member, authorized representative or a provider to reconsider the initial determination.
+200 points
Appeal
What is CMS?
+300 points
Centers for Medicare and Medicaid Services
What is PPFS?
Private Fee for Service
This part of Medicare covers Medical Insurance.
Part B
This is a special way of caring for people who are terminally ill, and for their family.
+200 points
Hospice
Are safe and effective for use by the general public without a doctor’s prescription.
+150 points
Over the counter (OTC)
The amount a member is required to pay out-of-pocket during a calendar year for covered Part A (Hospital Insurance) and Part B (Medical Insurance) services.
Maximum Out of Pocket
(MOOP)
Period of time beginning on the Plan anniversary date of any year and ending on the day before the same date of the following year.
+100 points
Plan Year
Notification to an insurance company that payment of an amount if due under the terms of a policy.
+100 points
Claim
Insurance providers use this to make sure that a specific medical service is really needed and worth the cost.
+200 points
Authorization
A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services.
+250 points
Skilled Nursing Facility (SNF)
This part of Medicare covers both Hospital and Medical plus additional benefits.
Part C
This is a way of caring for people in their own home rather than going to a facility.
+100 points
Home care services
These are drugs marketed under a propriety, trademark-protected name
Brand name drug
The actual dollar amount charged by a physician or other provider for medical services rendered, as distinguished from the allowable charge.
Charge Amount