Types of Insurance
This type of insurance plan requires members to get care from network providers and often needs a PCP referral.
What is an HMO?
These codes are used for outpatient services and procedures.
What are CPT codes?
This part of Medicare covers inpatient hospitalization stays.
What is Medicare Part A?
This form details the amount an insurance company pays and the patients' responsibility.
What is an EOB (Explanation of Benefits)?
This law protects patient privacy and health information.
What is HIPAA?
This plan offers more flexibility, allowing patients to see specialists without a referral.
What is a PPO?
This term describes the maximum yearly amount a patient will pay before insurance covers 100% of allowable charges.
What is the out-of-pocket maximum?
This part of Medicare covers outpatient services and physician visits.
What is Medicare Part B?
This is the fixed fee paid at the time of service.
What is a copay?
This act expanded Medicaid and allowed children to stay on their patents' plan until age 26.
What is the ACA (Affordable Care Act)?
A plan where high deductibles are offset by the ability to use Health Savings Accounts (HSAs).
What is a HDHP?
The difference between a provider's fee schedule and the insurance allowable amount.
What is a contractual adjustment?
This part of Medicare is offered through private plans and is sometimes called Medicare Advantage.
What is Medicare Part C?
What is coinsurance?
This law allows former employees to keep their health coverage after leaving employment for up to 18 months.
What is COBRA?
This government program provides coverage for children in low-income families who do not qualify for Medicaid.
What is CHIP?
These 5 to 7-character alphanumeric codes identify diagnoses.
What are ICD-10 Codes?
This part of Medicare helps cover prescription drug costs.
What is Medicare Part D?
These groupings reimburse hospitals a set amount based on patient diagnosis.
What are DRGs (Diagnosis-Related Groups)?
These entities ensure healthcare providers meet safety and quality standards.
Who are The Joint Commission?
This insurance allows employees to keep coverage for up to 18 months after leaving a job (at their own expense).
What is COBRA?
This reimbursement method pays a set amount per patient per month regardless of services provided.
What is capitation?
This program is jointly funded by the federal and state governments and is income-based.
What is Medicaid?
This process compares the insurance fee schedule to the provider's charges and determines payment.
What is claim adjudication?
This term describes the federally required coding and billing compliance program that healthcare facilities must follow.
Who is CMS compliance?