Insurance Basics
This person signs a contract with a health insurance company and owns the policy.
Who is the policyholder?
A network of providers that contract with insurers to offer discounted fees.
What is a PPO (Preferred Provider Organization)?
A fixed amount paid for services like office visits or ER visits.
What is a copayment?
Type of order from a provider allowing a patient to see a specialist.
What is a referral?
These providers accept discounted rates because they have signed a contract with the insurance company.
What is in‑network?
Insurance for adults 65+, those with disabilities, or end‑stage renal disease.
What is Medicare?
An insurance group providing care for a fixed annual fee.
What is an HMO (Health Maintenance Organization)?
The amount a patient must pay before insurance begins to cover costs.
What is the deductible?
A request to determine whether a service is covered under a patient’s plan.
What is precertification?
This term describes how much the patient must pay, including coinsurance, copayments, and deductibles.
What is patient financial responsibility?
Government‑administered insurance for low‑income families, children, and certain medical needs.
What is Medicaid?
Providers in this type of network agree to accept a discounted contracted rate.
What is in‑network?
The percentage of costs the patient pays after the deductible is met.
What is coinsurance?
Insurance may require this to confirm medical necessity before providing services.
What is preauthorization?
These include ICD‑10‑CM, ICD‑10‑PCS, CPT, and HCPCS.
What are code sets?
Supplemental insurance that helps pay Medicare deductibles or services not covered.
What is Medigap?
When more than one plan covers a patient, this determines which plan pays first.
What is coordination of benefits (COB)?
The periodic payment a policyholder makes to maintain coverage.
What is a premium?
This determines whether a person meets requirements to join a health plan.
What is eligibility?
Code set for encounters, services, and procedures reported by professionals.
What are CPT codes?
Insurance that fills any remaining gaps after primary and secondary coverage.
What is tertiary insurance?
The rule stating that whichever parent’s birthday comes first in the year determines the primary insurance.
What is the birthday rule?
The insurance plan that pays after the primary plan has processed the claim.
What is secondary insurance?
Written statements of medical care preferences, such as a living will.
What are advance directives?
This code set is used for diagnoses in all health care settings, including illnesses, conditions, and injuries.
What is ICD‑10‑CM?