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Terminology
Private Health Insurance
Medicare
Government Plans
Claims, Payments, and Legal
100

A fixed dollar amount that must be paid by the insured before additional expenses are covered by an insurer.

What is a Deductible?

100

This was established to provide partial medical care and income protection to employees who are injured or become ill from their job.

What is Workers Compensation

100
Offered to all medicare recipients to cover the cost of their prescription drugs.
What is Medicare Part D
100
A state to state health benefits program designed for low income people, and those who are blind, disabled, members of families with dependent children deprived of the support of at least one parent.
What is Medicaid.
100
A standard designed to protect medical records and all personal health information.
What is the Health Insurance Portability and Accountability Act
200

A rule that states that the insurance policy of a policyholder whose birthday comes first in the year is the primary payer for all dependents.

What is the birthday rule

200

A healthcare organization that provides specific services to individuals and their dependents who are enrolled in the plan. Doctors who enroll in an HMO agree to provide certain services in exchange for a prepaid fee.

What is a Health Maintenance Organization

200
Covers outpatient health care services, services by physicians and durable medical equipment.
What is Medicare Part B
200
What is a comprehensive health care program that the Office of Veterans' Affairs share the cost of covered health care services and supplies with eligible beneficiaries?
What is ChampVA
200
When an insurer determines whether an insurance claim is correct and able to be paid, and if so makes payment.
What is Claims Adjudication
300

A payment structure in which a health maintenance organization prepays an annual set fee per patient to a physician.

What is a Capitation

300

A group that takes nonstandard medical billing software formats and translates them into the standard EDI formats.

What is a Clearinghouse

300
Inpatient health care services, services in hospitals, nursing facilities, home health care, and hospice care.
What is Medicare Part A
300
A fee for service plan for the dependents of men and women in the military.
What is Tricare Standard
300
Medicare Part B coverage requires you to use this universal claim form.
What is a CMS 1500
400
The amount you pay each month to belong to a health plan.
What is a Premium?
400

A managed care plan that establishes a network of providers to perform services for plan members.

What is a Preferred Provider Organization

400
Some varieties of this plan may require members to pay a premium similar to the Medicare Part B premium.
What is Medicare Part C
400
A health maintenance organization plan with a point of service option for the dependents of men and women in the military.
What is Tricare Prime
400
The intentional deception or misrepresentation that results in unauthorized benefits to an individual or organization.
What is Health Insurance Fraud
500

A determination of the amount of money that will be paid by a third-party payer for a specific procedure before the procedure is conducted.

What is Precertification 

500

a system of health insurance payment in which a doctor or other health care provider is paid a fee for each particular service rendered, essentially rewarding medical providers for volume and quantity of services provided, regardless of the outcome.

What is a fee-for-service

500
Medicare is a federal program authorized by Congress and administered by this group.
What is Centers for Medicare & Medicaid Services
500
A preferred provider organization plan for the dependents of the men and women in the military.
What is Tricare Extra
500

A form that the patient and the practice receive for each encounter that outlines the amount billed by the practice, the amount allowed, the amount of subscriber liability, the amount paid, and notations of any service not covered, including an explanation of why that service is not covered; also called an explanation of benefits.

What is a Remittance Advice