A
What are payors referred to as?
Insurance Companies
What are patients referred to as?
Members
What is requested by the Payor based on the Patients treatment?
Payment
What is a person or thing that provides something?
Provider
What are the 2 types of plans?
Group and Individual
What type of Insurance Coverage has out of network benefit/coverage? Give two.
PPO PFFS HMO-POS
What type of Insurance Coverage only has benefits for in-network providers?
HMO
Which part of Medicare is Hosital Insurance?
Part A
Which part of Medicare is Medical Insurance ?
Part B
Which part of Medicare is for Prescription Drug plans?
What kind of physician is also referred to as gatekeeper?
Primary Care Physician (PCP)
This facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services.
SNF | Skilled Nursing Facility
A place other than a hospital that performs outpatient surgery or Day surgery.
Ambulatory Surgical Center
Special way of caring for people who are terminally ill, and for their family.
Hospice
A way of caring for people in their own home rather than going to a facility.
Home Health Services
These are drugs marketed under a propriety, trademark-protected name
Brand name drug
Generic drug has different active-ingredient formula as a brand name drug. True or False?
False.
Drugs that are safe and effective for use by the general public without a doctor’s prescription.
OTC Drugs
A medical specialty that uses medical imaging to diagnose and treat diseases.
Radiology
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Cognitive Therapy
U.S. Federal-State matching entitlement program that pays for medical assistance for needy individuals and families with low incomes and resources.
What federal agency administrates both Medicare and Medicaid?
Give 3 qualifications for someone to be eligible for Medicare.
Persons 65 years and over-must qualify by paying 10 years of 40 quarters of Social Security Tax prior to age 65
Persons Physically Disabled
Persons Diagnosed with permanent kidney failure ESRD (End state renal disease)
Spouses of those medically eligible (must meet above condition)
What is the difference between Explanation of Benefits and Explanation of Remittance?
EOB is sent to the member while EOR is for the provider.
The amount a member is required to pay out-of-pocket during a calendar year for. Until the maximum is set, the plan and member share in the cost of covered expenses.
MOOP