Key Terms
1. AWP (Average Wholesale Price)
The average price at which drugs are purchased at the wholesale level. It is mainly used to determine third-party reimbursement.
6. Coordination of Benefits (COB)
online billing of both a primary and a secondary insurer
11. Health Savings Account (HSA)
a tax-free savings account—funded by employees, employer, or both—to spend on routine medical costs. Usually combined with a high-deductible policy to pay for catastrophic care
16. Medicare Part B
medical insurance
21. online adjudication
Method of billing insurance companies and ensuring payment for services
2. Catastrophic Insurance
A type of accident insurance designed to provide lifelong medical, rehabilitation, and disability benefits for a victim of devastating injury
Copayment
a small fixed fee paid by the patient at the time of an office visit
12. ICD-10
A system to classify and code diagnoses, symptoms, and procedures
17. Medicare Part D
Prescription drug coverage
22. Out-of-network provider
a health care provider who is not in a particular managed care health insurance plan
3. COBRA Insurance
A federal program that allows a person terminated from their employer to retain health insurance they had with that employer for up to 18 months, or 36 months if the former employee is disabled.
8. Dual copay Insurance
coverage in which a patient pays one copay for brand name drugs and a lower copay for generic drugs; also known as two-tier.
13. in-network providers
providers in the plan
18. Medigap insurance
insurance provided by private insurance companies to cover medical expenses that are not covered by Medicare
23. Preferred Provider Organization (PPO)
4. Coinsurance
the percentage of the medical expenses the policyholder must pay in addition to the deductible amount
9. Dual eligible
An individual covered by both Medicare and Medicaid
14. Medicaid Federal
program that provides medical benefits for low-income persons.
19. monthly premium
monthly payment
24. Preferred drug list
a formulary provided by an insurance company that indicates preferred prescription generic and brand name drugs and their corresponding co-pays
5. Commercial Insurance
coverage for medical or prescription costs provided by an employer or purchased by an individual
10. Durable Medical Equipment (DME)
Includes certain medical supplies and equipment, such as ostomy supplies, hospital beds, oxygen tanks, walkers, and wheelchairs.
15. Medicare Part A
hospital insurance
20. NPI (National Provider Identifier)
a standard identifier for healthcare providers consisting of ten numbers
25. Pharmacy Benefit Manager (PBM)
The third-party administrator of prescription drug programs that processes and pays prescription drug claims.