Key Terms
AWP (Average Wholesale Price)
The average price at which drugs are purchased at the wholesale level. It is mainly used to determine third-party reimbursement.
online billing of both a primary and a secondary insurer
Coordination of Benefits (COB)
Health Savings Account (HSA)
a tax-free savings account—funded by employees, employer, or both—to spend on routine medical costs. Usually combined with a high-deductible policy to pay for catastrophic care
Medical Insurance
Medicare Part B
online adjudication
Method of billing insurance companies and ensuring payment for services
Catastrophic Insurance
A type of accident insurance designed to provide lifelong medical, rehabilitation, and disability benefits for a victim of devastating injury
a small fixed fee paid by the patient at the time of an office visit
Copayment
ICD-10
A system to classify and code diagnoses, symptoms, and procedures
Prescription drug coverage
Medicare Part D
Out-of-network provider
a health care provider who is not in a particular managed care health insurance plan
COBRA Insurance
A federal program that allows a person terminated from their employer to retain health insurance they had with that employer for up to 18 months, or 36 months if the former employee is disabled.
coverage in which a patient pays one copay for brand-name drugs and a lower copay for generic drugs; also known as two-tier.
Dual copay Insurance
in-network providers
providers in the plan
insurance provided by private insurance companies to cover medical expenses that are not covered by Medicare
Medigap insurance
Preferred Provider Organization (PPO)
a network of providers that contract to provide health services to a group of people
Coinsurance
the percentage of the medical expenses the policyholder must pay in addition to the deductible amount
An individual covered by both Medicare and Medicaid
Dual Eligible
Medicaid
a federal program that provides medical benefits for low-income persons.
Monthly Payment
monthly premium
Preferred drug list
a formulary provided by an insurance company that indicates preferred prescription generic and brand-name drugs and their corresponding co-pays
Commercial Insurance
coverage for medical or prescription costs provided by an employer or purchased by an individual
Includes certain medical supplies and equipment, such as ostomy supplies, hospital beds, oxygen tanks, walkers, and wheelchairs.
Durable Medical Equipment (DME)
Medicare Part A
Hospital Insurance
a standard identifier for healthcare providers consisting of ten numbers
NPI (National Provider Identifier)
Pharmacy Benefit Manager (PBM)
The third-party administrator of prescription drug programs that processes and pays prescription drug claims.