OUT OF POCKET
SET FEE DUE AT THE TIME OF THE OFFICE VISIT
WHAT IS THE COPAY?
This HMO primary care provider arranges for specialist services or hospitalizations
Who is the gatekeeper?
The insurance policy that pays first
What is the primary policy?
A standard claim form
What is a CMS-1500
Patients who qualify for this insurance are low income
What is Medicaid?
SET PERCENTAGE OF THE ALLOWED AMOUNT THE PATIENT IS RESPONSIBLE FOR PAYING
WHAT IS THE CO-INSURANCE?
This type of managed care insurance requires that the patient see contracted providers
What is an HMO?
The process of determining a patients benefits
What is VOB?
A claim with no errors
What is a clean claim?
Patients who qualify for this insurance are 65/+, ESRD, and disability
What is Medicare?
THE MONEY USED TO PURCHASE THE INSURANCE POLICY
WHAT IS THE PREMIUM?
HMO insurance providers will receive this type of payment for every patient that chose them as the PCP
What is a capitation?
The process of determining which insurance policy is primary and secondary
What is COB?
An outsourced company that will check claim to ensure they are clean
What is a clearing house?
Patients who qualify for this insurance are active duty, retire military and their family
What is TRICARE?
THE MONEY THE PATIENT HAS TO PAY BEFORE BENEFITS START
WHAT IS THE DEDUCTIBLE?
A provider that will accept MCO discounted reimbursement
Who are participating providers
This rule is applied when determining COB for dependent children
What is the Birthday Rule?
Codes used for procedures
What are CPT: Current Procedural Terminology Codes?
The government agency over Medicare and Medicaid regulations
What is the CMS: Center for Medicare and Medicaid services?
PATIENT HAS A 200 DEDUCTIBLE AND AN 80/20 COINSURANCE. IF THE ALLOWED AMOUNT FOR TODAY'S SERVICES IS $3,000, HOW MUCH IS THE PATIENT'S OUT OF POCKET FEES?
WHAT IS $760?
This MCO policy will allow patients to see selected providers at a discount but no referral is needed
What is a PPO?
This signature will give the provider permission to bill the insurance company on the patient's behalf
What is the assignment of benefits?
When the ICD codes justify the CPT codes on an insurance claim
What is medical necessity?
The CMS requires that this form is signed prior to performing labs on Medicare patients
What is the ABN: Advance Beneficiary Notice?