Abbreviations
Terms One
Terms Two
Prescriptions
100
A statement of benefits mailed to an insured or provider, which gives detailed information about the benefits, amount paid (if any) and the patient's responsibility.
What is EOB (Explanation of Benefits)?
100
An itemized statement of healthcare services and their costs provided by hospital, physician’s office, or other healthcare facility.
What is a claim?
100
Conditions, procedures, medications, and/or equipment not covered by the insurance policy.
What are exclusions?
100
Generic drugs; the least expensive
What is a tier one drug?
200
The amount that someone would pay out of their own pocket (costs not covered by insurance). This may include the deductible and/or co-insurance, depending on the plan.
What is OOP (Out of Pocket)?
200
A predetermined flat fee that an individual pays for health care services, in addition to what the insurance covers.
What is a co-payment?
200
Preferred generic drugs.
What is a tier two drug?
300
The official coding system for physician and hospitals to report certain outpatient services and professional services and procedures to third parties (i.e. insurance companies) for payment. It is produced and maintained by the American Medical Association.
What is CPT-4 (Current Procedural Terminology)?
300
The amount the insurance company will consider after all the non-covered amounts have been deducted…The basis for the deductible and co-insurance calculation.
What is allowable?
300
The amount of money that would need to be paid by the insured before the insurance pays and in addition to the deductible. For example, Joe meets his deductible for the year. He has a doctor visit that costs $100.00. His plan will pay 80% ($80.00) of the charge. The co-insurance that Joe is responsible for is 20% ($20.00).
What is co-insurance?
300
The maximum amount of money the health insurance policy will pay towards covered medical expenses for the insured person’s entire life.
What is a lifetime maximum?
400
A categorized listing of diagnosis and identifying codes used by physicians and hospital providers for reporting diagnoses of health plan members. The coding and terminology provides a uniform language that can classify primary and secondary diagnoses and provide reliable and consistent communication on claims forms.
What is ICD-9 (International Classification of Diseases)?
400
The amount of money someone has to pay before any benefits from a health plan can be used. This is usually a yearly amount so when the policy starts again, usually after a year, it would be in effect again. Some services, like doctor visits, may be available without meeting this first, depending on the plan.
What is the deductible?
400
The amount of expense a family (insured person plus his/her dependents) must pay before benefits can be used. Although these vary, they are generally a multiple of the individual deductible (i.e., two or three), and may be a combination of accumulated expenses from several different family members
What is a family deductible?
400
Non-preferred brand name drugs; most expensive.
What is a tier four drug?
500
A system to classify hospital cases into one of approximately 500 groups expected to have similar hospital resource use. They are used to determine how much Medicare pays the hospital, since patients within each category are similar clinically and are expected to use the same level of hospital resources.
What is a DRG (Diagnostic Related Group)?
500
The amount of money the insured person is responsible for paying after the insurance company has made payment. This could include co-insurance, copayments and non-covered charges.
What is the patient’s responsibility?
500
This refers to the company, association, or group of employers that select us to administer their plan benefits.
What is a policyholder?
500
Under this plan, certain services are considered “basic” and paid at 100% without deductibles or out-of-pocket expenses. Under Major Medical Expense, services are subject to deductibles and out-of-pocket expenses and are reimbursed at the plan’s co-insurance rate.
What is Basic/Major Medical Expense (BMME)?
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