Insurance
What else is the insurance carrier referred to as?
"Health plan" EX: BCBS
What is the largest federal program providing healthcare, which provides health insurance to citizens over 65 years old
Medicare
what is a nationwide federation of nonprofit and for-profit service organizations that provide prepaid health care services to its subscribers, each state operate under its own rules
BCBS
When the insurance carrier reviews each claim to determine whether the procedures provided, and the accompanying diagnoses are compatible and whether the treatment is indeed needed
medical necessity
What is a physicians establish a list of their usual fees charged to most of their patients most of the time under typical conditions
Fee Schedule
What else is the policy holder referred to as?
may also be referred to as "the insured," "the member," or "the subscriber."
what is the form that must be verbally reviewed with the beneficiary or their representative and any questions raised during that interview must be answered before it is signed. Helps patients consider all their options to make an informed choice (informed consent)
ABN Advanced beneficiary notice
Covers families of veterans with total, permanent, service-connected disabilities. Also covers surviving spouses and dependents of veterans who died in the line of duty or as a result of service-connected disabilities
CHAMPVA
When the insurance department compares the fee the doctor charges with the benefits provided by the patient's health plan
review for allowable benefits
How do managed care plans pay their providers?
by either contracted fees or fixed prepayment called capitation
What is usually paid monthly, is the amount the policyholder pays the insurance company for insurance coverage annually
Premium
Which medicare covers Inpatient care (up to 90 days), Skilled Nursing Facility, Home health care, Hospice care, Some mental health services and Limited respite services
Medicare Part A
People who are enrolled in are age 65 or older can receive healthcare at a military treatment center.
TRICARE for Life
what is the receipt of confirmation form a patient's insurance plan that the proposed service or procedure will be considered a covered service because of the individuals' specific circumstances
preauthorization
What is a fixed prepayment
capitation
Are what the insurance company pays for a specified time
Benefits
What medicare covers Outpatient procedures/supplies, voluntary program, patients must choose to enroll
Medicare part B
Allows states to provide health coverage to uninsured children in families whose incomes are too high to qualify for Medicaid but too low to afford private insurance.
CHIP/SCHIP
What is the process of confirming with the insurance company that a patient's insurance plan offers coverage for a specific procedure or service BEFORE scheduling
Precertification
In instances of this dual coverage, the person whose birthday is first in the calendar year will be considered the primary payer this is called the _______
birthday rule
What is the form that patients are asked to sign in which the provider agrees to prepare healthcare claims for patients, receive payments directly from payers, and accept a payers allowed charges.
Assignment of Benefits
What medicare covers prescription drug plan
Medicare part D
Covers employment-related accidents and diseases. Federal law requires employers to purchase and maintain a certain minimum amount of workers' compensation insurance for their employees; however, laws vary from state to state, files must be kept seperate
Workers Compensation
What is a "planned" procedure not usually covered by insurance
elective procedure
What are claims that are accepted for processing by the payer
clean claims