General Insurance
Hospital
Issue/Denial
Patient Responsibility
Provider
100

Covered Services

What is a service (or test, supply, procedure) that an insurance company pays the patient or provider for?

100

DOS

What is the Date of Service; Date patient received healthcare services

100
Dates between which a patient has insurance coverage.
What are the Effective and Termination Dates?
100
The minimum patients must pay before their insurance compnay makes any payment.
What is a deductible?
100
Any supplier of health-care services: Physicians, Pharmacists, Physician Assistants, Physical therapist, Nurse Practitioners.
What is a Provider?
200

The discount taken by the Insurance company based upon the contract between INS and the hospital.

What is an Adjustment?

200

Current Procedural Terminology

What is CPT codes; 5 digit code describing services done?

200
Health problem(s) experienced by a patient before a new insurance policy starts.
What is a Pre-existing condition?
200
Document telling patient how a specific claim was processed and the total patient responsibility.
What is the Explanation of Benefits (EOB)?
200
A chronological written account of a patient's examination and treatment that includes the patient's medical history and complaints, the physician's physical findings, the results of diagnostic tests and procedures, and medications and therapeutic procedures.
What are Medical Records?
300

One is for facility based charges and the other is for professional charges.

What is the difference between a UB Claim form and a 1500 Claim form?

300

Services provided by physicians, pharmacists, physician assistant, physical therapists or nurse practitioners.

What is Professional Services?

300
The length of time after a DOS an insurance company will accept claims for payment.
What is Timely Filing?
300
One receives and pays bills, one pays the insurance premiums and one received care on DOS.
What is the difference between the Guarantor, Subscriber and Patient?
300
*****BONUS***** Can you determine patient responsibility by looking at the Summary Screen in meditech?
NOOOOOOO!!!!!
400

Listing of max amounts a health insurance plan will pay for certain CPT codes in 1 year.

What is the Fee Schedule?

400

Whether a patient was admitted to the hospital or not.

What is Inpatient vs. Outpatient?

400
Coordination of Benefits
What is COB; agreement on how to process charges between more than one health insurance company?
400
Total co-insurance patient must pay before insurance pays 100%.
What is the maximum out-of-pocket?
400
A facility that provides services to a patient that is not contracted with the patient's insurance company.
What is an Out-of-Network provider?
500

The 5 categories of Insurance we discussed: 1 insurance can belong to more than 1 of these.

What is Primary, Secondary, Tertiary, Supplemental, Replacement ?

500

International Statistical Classification of Diseases and Related Health Problems

What is ICD Codes; classifies diseases, symptoms, findings, complaints?

500
Services that meet standards of good medical practice in the local area.
What are Medically Necessary services?
500
Required by insurance to confirm medical necessity of procedure BEFORE being done.
What is a pre-certification/ pre-authorization?
500
The difference between what an insurance company approves according to their contract and what the health-care provider charges for the procedure.
What is a Contractual Adjustment?
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