Government Plans
The federal health insurance program that provides coverage for individuals who are age 65 Y or older, the disabled and those diagnosed with ESRD
What is medicare
what is an employer group plan
health insurance companies whose goal is to provide quality, cost-effective care to its members
MCOs (managed care organizations)
process of confirming health insurance coverage for the patient
what is Verification of eligibility
percentage of costs of a covered healthcare service the policyholder pays after the deductible has been paid
What is coinsurance
State administered healthcare program that assists the indigent
what is medicaid (mediCal or Buckeye Health
an individual health insurance plan covering just one person, purchased directly from insurance company or through the health insurance exchange
individual health insurance plan
This type pays for all or share of cost of covered services
Traditional health insurance
process of determining if a procedure or service is covered by the insurance plan and what the reimbursement is for that procedure or service
What is precertification
set dollar amount that the policyholder must pay before the insurance company starts to pay for services
What is deductible
program for children whose family income is above the medicaid qualifying limit
CHIP
an insurance plan arrangement where the employer provides health benefits to employees through their own funds
self-funded group health plan
health plans that are regulated by HMO laws, which require them to include preventive care as part of their benefits package
health maintenance organizations
Referral that usually takes 3 to 10 working days for review and approval
what is a regular referral
set dollar amount that the policyholder must pay for each office visit
What is copay
program for active duty and retired members of uniformed services, their families and survivors.
Tricare
An organization that processes claims and provides administrative services for another organization
Third-party administrators
managed care network that contracts with a group of providers
what is a preferred provider organization
Referral that can be approved online when it is submitted to the utilization review department through the provider's web portal, used in emergency situations
what is a STAT referral
healthcare provider who signed a contract with an insurance company, managed care plan, or a government health plan to provide services to policyholders
What is PAR
provides coverage for the spouse and children of a disabled veteran or deceased veteran
CHAMPVA
Who is the largest private insurance company in the US?
What is Blue Cross/Blue Shield
this type combines features of an HMO and a PPO, services are not covered if the provider/facility is outside of the network.
what is an exclusive provider organization
Referral that usually takes 24 hours for approval, for non life-threatening situations
What is an urgent referral
insurance term used when a primary care provider wants to send a patient to a specialist
What is referral
the largest healthcare system in the US, serves veterans
VHA or VA
What is fee-for-service
form of patient care review by healthcare professionals who do not provide the care but are employed by health insurance companies
what is utilization management/review
Insurance for instances where employees are unable to work more than 53 weeks and up to the numbers of years specified in the policy
what is long term disability insurance
process that requires the provider to submit documentation to the payer to show the service or treatment is medically needed
What is preauthorization or prior authorization
publicly sponsored system that pay monetary benefits to workers injured or disabled in the course of employment
what is Worker's Compensation
What is the type of insurance that only covers catastrophes?
what is major medical or catastrophic coverage.
practice provider or provider group that practices independently and may contract with several HMOs
What is an independent practice association
insurance that will provide replacement income for 9-52 weeks
what is short term disability insurance
payment arrangement where provider is paid a set amount for each enrolled person assigned to them, per period of time, whether or not that person has received services
What is capitation