Very Easy
What PCP means?
Primary Care Physicians
Refers to a person or entity that delivers healthcare services. This can include doctors, hospitals, specialists, therapists, and other medical professionals or facilities.
Provider
Type of complaint on the quality of care.
Grievance
Time given by insurance company to the providers to submit the claim after giving the service to a patient.
Timely Filling Limit (TFL)
What are the four (4) plans that is being offered by Medicare?
Plan A, B, C and D.
What age can be a member eligible for Medicare?
65 years old and above
Amount paid (usually monthly) to have a plan.
Premium
Providers who do not have a contract with an insurance company are known as out of network/non participating providers.
Out of network/Non Participating providers
Requirement of some payors that the patients expected care for specific service must be first approved by the payor before the service are rendered
Precertification or Authorization
A standardized form that are used by the providers to bill the insurer/ payor.
Claim Form
Medicare beneficiary enrolled in an Aetna plan
Member
The amount a member must pay out-of-pocket each year before the Medicare plan begins sharing costs
Deductible
Complete diagnosis code by indicating what treatment or procedure was performed during a patient's visit.
Procedure Code
Approval given by primary care Physician (PCP) to a member to receive care from a participating specialist.
Whose conditions are not stable and/or frail members receive care from Physician Assistant or Nurse Practioner.
Chronically ill patients
Medicare beneficiary not yet enrolled and is shopping for a plan.
Prospect
Providers who have a contract with an insurance company.
Network / Participating Providers
Insurance company will make the payment based on the contract.
Allowable amount
Is a request for reconsideration on a service or a claim that was denied.
Appeal
Refers to any data about members that is created or collected by healthcare providers, health plans, employer or healthcare clearinghouse.
PHI- Protected Health Information
What CMS stands for?
Centers for Medicare and Medicaid Services
Sell healthcare products such as Durable Medical Equipment (DME), drugs, injections, surgical instruments and diagnostic equipment to the providers.
Supplier
A time frame given by the payor to the provider for submitting their appeals
Appeals Filing Limit
Give 2 out of 4 plans offered by MCO or Managed Care Organization Plans.
• Health Maintenance Organization (HMO)
• Preferred Provider Organization (PPO)
• Point of Service (POS)
• Exclusive Provider Organization (EPO)
Protects patients medical Information
Ensure health insurance coverage
Prevent healthcare fraud and abuse
HIPAA
-Health Insurance Portability and Accountability Act