Insurance Terms
This is an online marketplace where you can compare and buy individual health insurance plans
What is Health Insurance Exchange
This program is for those over the age of ____ and eligible for social security benefits
What is 65
Medicaid is funded by who
What is State & Federal
HMO
What is Health Maintenance Organization-must see provider in network
Demographic information needed for a claim is entered at
What is at scheduled appointment or prior on the phone
This Tricare plan covers active duty members and their families
what is Tricare Prime
A designated person who receives funds from an insurance policy
What is beneficiary
Is Medicare federally or state funded?
What is federally
Medicaid specifically is for those who are poor, needy, or impoverished also known as what
Indigent
PPO
What is Preferred Provider Organization-can see provider in or out of network
List of charges for services or procedures
What is a fee schedule
This plan is for veterans with permanent service related disabilities and their spouse and children
What is Champva
A payment arrangement for healthcare providers in which the provider is paid a set amount regardless of whether the patient has or has not received services
What is capitation
Medicare part ____ includes prescription drug coverage
What is part D
Medicaid was signed into law in what year
What is 1965
ICD-10-CM
International Classification of Diseases, Tenth Revision, Clinical Modification- way to document various diseases, disorders, injuries, and other health conditions, supporting accurate and detailed disease classification for effective healthcare management
Assignment of Benefits allows
What is physicians to receive payment directly from an insurance company for services rendered to a patient.
This is a self-managed, preferred provider organization (PPO) health plan that allows you to see any TRICARE-authorized provider, but you'll pay lower out-of-pocket costs if you use a network provider
What is Tricare Select
A written agreement between two parties in which one party agrees to pay another party if certain specified circumstances occur is called a what
What is a policy
Part of Medicare that pays 100% of first 60 days of hospitalization
What is Part A
This program provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid
What is CHIPS- Children's Health Insurance Plan
CPT
What is Current Procedural Terminology- codes for medical procedures
Form used for filing paper claims
What is the CMS-1500
This is a managed care option available in remote areas in the U.S. By law, you can only use if both your sponsor’s home and work addresses are more than 50 miles (or a one-hour drive time) from a military hospital or clinic
What is Tricare Prime Remote
Services or supplies that are used to treat the patient's diagnosis that meet the accepted standard of medical practice is known as what
Medically necessity
Part of Medicare that pays outpatient services
what is Part B
Medicaid, while covering essential healthcare, typically excludes services like what
What is elective cosmetic procedures, experimental treatments, non-emergency transportation, and certain types of care like infertility treatments and elective abortions
RBVS
Resource-Based Relative Value Scale- a system used in the US to determine the amount of money insurers pay healthcare providers for their services, based on the resources required for each service, including physician work, practice expense, and professional liability insurance
What is a clearinghouse
What is 3rd party that standardizes claims & checks for errors before submitting for payment
This is a Medicare-wraparound coverage if you’re TRICARE-eligible and have Medicare Part A and B, regardless of age or place of residence. Coverage is only for those with Medicare and who are TRICARE-eligible. Coverage doesn’t extend to family members.
What is Tricare for Life
A list of the fixed fees for service is known as a what
What is a fee schedule
Medicare part ___ covers both inpatient and out patient services
What is part C
Name 4 types of individuals who may qualify for medicaid
What are low income families, children in foster care, blind, medically needy, some over 65yrs
EOB
What is Explanation of Benefits- details how much an insurance company will pay for the patient's medical services, which allows the provider to verify the accuracy of the claim/ also for patient to see breakdown between insurance payment and their responsibility
response from insurance company to provider showing payment breakdown
What is Admittance Advice
By law, Tricare pays after all other health insurance except for what
What is Medicare, Tricare supplements, and state victims of a crime compensation program
To settle or determine with a court of law is known as what
What is adjudicate
When individuals are "dually eligible" for Medicare and Medicaid, which one is billed first
What is Medicare
This program provides comprehensive services to individuals age 55 and older in Kentucky who need nursing facility level of care but prefer to continue living at home
What is PACE- Programs of All-Inclusive Care for the Elderly
NPI
National Provider Identifier- the identifier that is assigned to healthcare providers by license and medical specialties
This compares the physicians fee with benefits provided by the patients health plan
What is Review of Allowable Benefits
In order to enroll in any Tricare insurance plans you must be in this system
What is DEERS- Defense Enrollment Eligibility Reporting System