Insurance Basics
This is a contract between an insured and insurer outlining coverage and responsibilities.
What is a policy?
This plan requires patients to choose a primary care provider and obtain referrals.
What is an HMO (Health Maintenance Organization)?
This federal program primarily serves individuals 65 and older.
What is Medicare?
This standardized form is used to submit provider claims to insurance companies.
What is the CMS-1500 form?
A fixed amount the patient pays for a service is called this.
What is a copayment?
A patient has a $500 deductible and has paid $300. They receive a $200 service. How much will insurance pay?
What is $0 (patient pays remaining deductible)?
This term refers to the amount paid periodically to maintain insurance coverage.
What is a premium?
This plan allows more flexibility in choosing providers but costs more.
What is a PPO (Preferred Provider Organization)?
This joint federal and state program provides coverage for low-income individuals.
What is Medicaid?
This code system is used to report diagnoses.
What is ICD-10-CM?
This is the percentage of costs the patient pays after the deductible is met.
What is coinsurance?
If a provider accepts assignment, what does this mean?
What is the provider agrees to accept the insurer’s allowed amount as full payment?
The portion the patient must pay before insurance begins to pay is called this.
What is a deductible?
This type of plan combines features of HMO and PPO.
What is a POS (Point of Service) plan?
This Medicare option includes private insurance plans approved by Medicare.
What is Medicare Part C (Medicare Advantage)?
This code system is used to report procedures and services.
What is CPT?
This term refers to the total amount a patient must pay out-of-pocket before insurance covers 100%.
What is out-of-pocket maximum?
A claim is denied due to lack of medical necessity. What is the most appropriate next step?
What is submit an appeal with supporting documentation?
This describes services not covered under a policy.
What are exclusions?
This type of coverage is purchased by an individual, not through an employer.
What is individual insurance?
This part of Medicare covers hospital stays.
What is Medicare Part A?
This process checks patient insurance eligibility and benefits before services.
What is verification of benefits?
This agreement allows patients to pay balances over time.
What is a payment plan?
A patient is seen out-of-network in a PPO plan. What is the likely financial impact?
What is higher out-of-pocket costs and reduced coverage?
This term refers to the maximum amount an insurer will pay for a covered service.
What is the allowed amount (or maximum benefit)?
This plan reimburses providers based on services rendered, often called fee-for-service.
What is an indemnity plan?
This part of Medicare covers outpatient services and physician visits.
What is Medicare Part B?
This document explains how a claim was processed and payment determined.
What is an Explanation of Benefits (EOB)?
This federal law requires providers to give patients cost estimates before services.
What is the No Surprises Act (Good Faith Estimate requirement)?
A claim is rejected due to incorrect patient information. What distinguishes rejection from denial?
What is a rejection occurs before processing and can be corrected/resubmitted, while a denial occurs after processing and requires appeal?