Fall 2025 Final Study

Insurance "Who"

100

This person is responsible for payments of all medical bills under the insurance 

Guarantor 

200

This can be the family of the policy holder, such as children or spouse 

Dependent 

300

This person is often referred to as the gatekeeper in insurance 

The PCP

400

This is used to determine which insurance will cover a child in the case of two separate insurance plans

The birthday rule 

500

The patient is often referred to as this with an insurance company 

first party

Paperwork

100

This is often referred to as the subscriber form and is provided to the subscriber in regards to a summary of coverage 

Explanation of Benefits EOB  

200

This is also called the provider form and is a summary of coverage after an insurance claim is made  

Remittance Advice Statement (RA) 

300

There are private insurers contracted to manage Medicare claims in a specific geographical region

Medicare Administrative Contracts 

400

This is a form required by Medicare to let patients know that a service will not be covered 

Advance Beneficiary Notice 

500

This is the standard insurance form used for paper billing  

CMS-1500

Payment

100

After this is reached, the insurance company will pay 100% of healthcare costs 

Out-Of-Pocket maximum 

200

This must be paid monthly to maintain eligibility 

Premium 

300

Some insurance policies requires that this must be met in order for the insurance company to pay any healthcare costs 

Deductible 

400

This is a set amount that mush be paid for each visit 

Copayment 

500

This is a request for payment 

Claim 

Types of Insurance

100

This is administered and operated at the state level. 

Medicaid 

200

This is a federal health insurance program for people 65 and older 

Medicare 

300

This is the health insurance program of the US military 

TRICARE 

400

This provides low-cost health insurance for children in families that have lower incomes but earn too much to qualify for Medicaid 

CHIP or Children's Health Insurance Program

500

This provides health insurance benefits to dependents of military veterans who were disabled or killed in the line of duty 

CHAMPVA 

Billing and Coding

100

This is the system created by the World Health Organization to track morbidity  

International Classification of Diseases or ICD 

200

A code with adequate detail to present to an insurer as part of a claim 

Billable 

300

An interaction between a patient and a provider that may be billed/generate an insurance claim 

Encounter 

400

This is the standard coding set used to bill insurers for most outpatient care 

CPT Code 

500

A review of diagnosis and procedure codes to ensure that they follow the correct guidelines

Audit