Miscellaneous Part 1
The dollar amount considered payment in full by an insurance company
What is an Allowable Charge?
A specific charge that the health insurance plan may require that the patient pay for a specific medical service or supply.
What is a Co-Payment
The payment of health insurance benefits directly to the provider rather than to the member of a health insurance plan.
What is "Assignment of Benefits."
An organization of providers who may maintain separate offices but who negotiate contracts with insurance companies and medical facilities as a group
What is an Individual Practice Association (IPA)?
A state-funded healthcare program for low income and disabled persons
What is Medicaid (Medi-Cal)?
An event such as termination of employment, divorce or death of the employee that triggers a group health insurance member's protection under COBRA
What is a Qualifying Event?
A specific dollar amount that the health insurance company may require the patient to pay out-of-pocket each year before the health insurance plan begins to make payments for claims.
Deductible
A statement sent from the health insurance company to a member listing services that were billed by the healthcare provider, how those charges were processed and the total amount of patient responsibility for a claim.
What is Explanation of Benefits (EOB)
A healthcare professional who has a contractual relationship with a health insurance company
What is a Network Provider?
A national, federally administered health insurance program to cover many health care costs for most people over 65 and certain other eligible individuals
What is Medicare?
Process by which an insurance company decides whether medical bills should be paid by the insurance company or by another entity.
What is Subrogation?
Amount a patient is obligated to pay for covered medical services after they have satisfied any co-payment or deductible required by the health insurance plan.
What is Coinsurance
What is an Indemnity Plan?
Process by which a healthcare specialists review the care provided by another provider.
Peer Review
Anyone covered under a health insurance plan, an enrollee or eligible dependent.
What is a member?
The standard or most common charge for a particular medical service when rende3red in a particular geographic area.
What is the Usual, Customary and Reasonable (UCR) charge?
A tax advantaged savings account to be used in conjunction with certain high-deductible (low premium) health insurance plans to pay for qualifying medical expenses. Contributions may be made tax free.
What is a Health Savings Account (HSA)?
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 policy.
What is "Coordination of Benefits?"
Time period during which eligible persons or employees may sign up for coverage under a group health insurance plan.
What is an Open Enrollment Period
Group of healthcare professionals who work with insurance companies to determine if a patient's use of healthcare services was medically necessary, appropriate, and within the guidelines of standard medical practice.
What is Utilization Management (Utilization Review, UR)
Termination of insurance coverage due to lack of payment after a specific period of time
What is an Insurance Lapse?
Type of facility where healthcare services were provided
What is place of service?