Benefit Details
The annual cycle in which a health insurance plan operates
Benefit Year
A group of nurses and doctors who determine if a patient's use of healthcare services was medically necessary, appropriate, and within the guidelines of standard medical practice
Utilization Management Review
Healthcare rendered to a patient outside of the health insurance company's network of preferred providers.
Out of Network
The claim is processed by the payer and determined to be unpayable.
Denial
This law provides numerous rights and protections that make health coverage more fair and easy to understand, along with subsidies (through “premium tax credits” and “cost-sharing reductions”) to make it more affordable.The law also expands the Medicaid program to cover more people with low incomes.
ACA - Affordable Care Act
The maximum amount a health insurance company agrees to pay for a specific covered benefit
Benefit Level
Insurance plan may require a prior authorization should one line item exceed a certain limit.
Line Item Limitation
Healthcare services are typically not covered outside the network, there may be exceptions in the case of an emergency. Name the plan type.
HMO - Health Maintenance Organization
Medicare and other insurance carriers have their own guidelines for filing claims within a certain time frame. Failure to submit claims within that time frame can lead to denials.
Timely Filling
This is the process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance plan
COB - Coordination of Benefits
A tax advantaged savings account to be used to pay for qualifying medical expenses
HSA (Health Savings Account)
A basic criterion used by health insurance companies to determine if healthcare services should be covered.
Medical Necessity
This is an identification number that is strictly associated with a member
What is Member ID?
Paying for a set of services, not “per unit of care delivered' under the fee-for-service model, and is a single payment to providers or health care facilities for all services to treat a given condition or provide a given treatment.
Bundled Payment
A provider's usual fee for a service does not exceed the customary fee in that geographic area and is reasonable based on the circumstances
UCR Charges - Usual, Customary, & Reasonable
Supplies that may be obtained without a prescription
OTC - Over the Counter
Items or services that aren't covered under a given health plan and for which the plan won’t pay and are specified in the plan
Exclusions
During this time your insurance deductible, coinsurance, and out of pocket amounts reset
Refresh Dates
Two-digit codes that modify a service/procedure or an item under certain circumstances for appropriate reimbursement.
Modifiers
A written agreement by the insurance company approving service. This agreement will typically include approved date range, HCPCs, description, number of units and costs.
IPA - Insurance Payment Agreement
The dollar amount the patient is responsible for before insurance benefits kick in
Deductible
For a member to receive the highest coverage for procedures or services a _____ must be obtained
PCP Referrals
The enrollees may go outside the network, however would incur large costs in the form of a higher deductible, higher coinsurance rates, and non-discounted charges from the providers. Name the plan type.
PPO - Preferred Provider Organization
Either full or partial payment has been received for claims that have been submitted
Payment History
For a member to receive the highest coverage for procedures or services a ___ must be obtained
PCP Referral