Permission obtained from a payer for services to be provided
What is Preauthorization?
100
Money that the insured must pay to a health plan for a policy to be in effect.
What is a Premium?
200
Monies owed to the Practice
What is Accounts Receivable?
200
A payers review and reduction of a procedure code (and payment)
What is Downcoding?
200
A person or entity that supplies medical or health services and bills for those services
What is a Provider?
200
Care provided to keep patients healthy or prevent illness
What is Preventive Care?
200
A fixed amount that a beneficiary must pay at the tome of the encounter.
What is a Copayment?
300
The maximum amount that a plan will pay for a service or procedure.
What is an Allowed Charge?
300
Monies that are owed by the practice
What is Accounts Payable?
300
Private or government organization that insures or pays for healthcare on behalf of beneficiaries
What are Third Party Payers?
300
Services not covered in a medical insurance contract
What are Excluded Services?
300
The amount of money the insured must pay for health services before a health plan's payments begin
What is a Deductible?
400
A fixed prepayment covering providers services for a plan member for a specified period
What is Capitation?
400
A provider who does not have a participation agreement with a plan.
What is Out of Network
?
400
A person or entity exercising the right to receive benefits
What is a Claimant?
400
An electronic transaction or a paper document filed to receive benefits
What is a Healthcare Claim?
400
A percentage of the charges the insured must pay for healthcare services after the deductible has been met.
What is Coinsurance?
500
A statement sent to the patient after the 3rd party has made their determination and payment
What is Balance Billing?
500
One who appeals a claim decision
What is an Appelant?
500
A group of providers, including physicians and hospitals, who sign a contract to receive capitated payments in return for reduced charges for plan members.
What is a Network?
500
An illness or disorder that existed before the insurance coverage became effective.