Payor Types
What is the term for an organization that pays healthcare services on behalf of patients
Payor
What federal program provides health insurance for individuals over 65?
Medicare
What is the term for the amount a patient pays out of pocket before insurance starts covering costs?
Deductible
What type of insurance plan requires patients to choose a PCP?
HMO
What is the standard form to submit medical claims?
CMS 1500 form
Name the two main types of payors in the healthcare system
Private and Public
What state and federal program provides health coverage for low-income individuals
Medicaid
What is co-insurance in health care?
The percentage of costs a patient pays after meeting their deductible
What is the main feature of the PPO plan?
Patients can see out of network providers but for a higher cost
What does ICD stand for in medical billing
International Classification of Diseases
What type of payor is Medicare
Public Payor
What is the CHIP program designed to do?
Cover children whose family makes too much for Medicaid but cannot afford private insurance
What does the allowed amount mean?
The maximum amount an insurance plan will pay for a covered service
What does a HDHP often pair with to help save money?
HSA
What is the purpose of a CPT code in medical billing
To describe medical, surgical, and diagnostic services provided
What type of payor is commerical health insurance company like BCBS
Private Payor
What is the difference between Medicare A and Medicare B?
Medicare A covers hospital and Medicare B covers Medical (outpatient)
What is the difference between a copay and a deductible?
A copayment is a fixed amount paid for a service, while a deductible is the amount paid before insurance coverage begins
What is the main difference between an HMO and PPO?
HMOs require referrals for specialists, while PPOs do not.
What is the difference between a clean claim and a denied claim?
What is the role of a third-party administrator in insurance?
They process claims and manage benefits for self-insured employers
What is the purpose of Tricare?
What is the explanation of benefits (EOB)
A statement from the insurance company stating the amount that will be covered for services rendered
What is COBRA
It requires that your employer must keep you on their insurance plan for up to 18 months after you leave the company, at your expense
What is the role of a clearinghouse in medical billing?
To process and transmit claims between healthcare providers and insurance companies