What it is?
What does ERISA stand for?
What is Employee Retirement Income Security Act.
What does PPO stand for?
What is Participating Provider Organization (In Netwrok).
What is a Co-pay?
What is the fixed amount a patient pays up front for services.
What is a CPT Code?
What is Current Procedural Terminology, a 5 digit numeric code with narrative descriptions used for reporting medical services and procedures performed by health care providers.
What type of plan has In-Network benefits only?
HMO - Health Maintenance Organization
What does COBRA stand for?
What is Consolidated Omnibus Budget Reconciliation Act.
What does NPPO stand for?
What is Non-Participating Provider Organization (Out of Network).
What is OOP max?
What is the maximum dollar amount the member will pay in a plan year for covered services.
What is HCPCS?
What is Health Care Procedure Coding System, a 5 digit Alphanumeric code used to report supplies, materials, injections and services.
Why would you need to submit for Pre-Certification?
What is to determine if certain services/procedures are "Medically Necessary"?
What does PPACA stand for?
What is Patient Protection and Affordable Care Act.
What does Embedded mean on a HDHP?
What is the maximum dollar amount a single person could pay. Could apply to Deductible/OOP depending on plan language.
If George's deductible is $500 and he has met $350 and the Allowed Amount for the charges was $150 how much would George pay?
What is $150.
What is ICD-10?
What is Diagnosis Codes, 3-7 digit alphanumeric code used to describe illnesses, injuries, signs, symptoms, and procedures.
What type of plan has In-Network and Out-of-Network benefits?
PPO- Preferred Provider Organization
What is the difference in Grandfathered vs Non-Grandfathered?
What is Non-Grandfathered is required by federal law to cover certain in-network preventative services with no cost share to patients.
What is a Deductible?
What is the amount the patient pays for services before insurance begins to pay.
If George's OOP is $1500 and he has met $1150 and the Allowed Amount for the charges was $1300 how much would George pay?
What is $950.
What is Out-of-Network?
Providers who do NOT have a contract in place with the Insurance company.
What is a Double Withhold?
What is the provider is the same as the group and no "payment" is issued?
What is an "allowed amount"?
What is Contracted Rate (PPO) or Recognized Charge (NPPO).
What is Coinsurance?
What is the percentage the plan will pay based on the Allowed Amount.
What is the difference in Calendar Year vs. Plan Year?
What is Calendar Year runs 1/1/2026-12/31/2026 where as Plan Year may run from 7/1/2026-6/31/2027.
What is In-Network?
Providers who have a contract in place with the Insurance company.
What are forms that are the standardized forms for individual doctors, nurses, practices and other professionals?
HCFA Form (CMS-1500)