Plan related
Terms
Medical
Acronym
Parts
Easy Peasy
Drugs
$$$
100

A provider who does not sign a contract to participate in a health plan and who refuses to accept insurance allowable as payment in full.


+200 points

What is OON/ Non-par

100

Is the person who is/will receive medical treatment. Is also referred to as a member

What is Patient

100

Generally, a legal spouse or child who meet eligibility requirements of the policy

What is Dependent  

100

What is HMO?

What is Health Maintenance Organization

100

A twelve-month period that begins on January 1 and ends twelve consecutive months later on December 31

What is Calendar Year

100

A physician who is trained in general medical care and treats routine problems. Members have them as their regular doctors/physicians.


+100 points

What is Primary Care physician (PCP)

100

Are required when your prescription gets low. Some prescriptions don't come with this because your prescriber may feel you only need a certain amount to feel better.


+100 points

What is Refill

100

A fixed amount per contractual period that a patient pays before health insurance will begin to pay; this is only paid if provider services are obtained

○ Amount represented in dollar amount ($).

+200 points

What is Deductible

200

This means that a healthcare provider has a contract with a health insurance plan to provide services at a lower rate to the plan members.


+100 points

What is INN/PAR

200

It is defined as health professionals who provide healthcare services.

What is Provider

200

Is a U.S. Federal-State matching entitlement program that pays for medical assistance for needy individuals and families with low incomes and resources.


+200 points

What is Medicaid

200

PPO


+100 points

What is Preferred Provider Organization

200

This part of Medicare covers Prescription Drugs or RX


+100 points

What is Part D

200

A physician who has more advanced medical training than a primary care physician and is certified to practice in a specific field. They treat complicated medical conditions in his specific area of training and is generally more expensive than a primary care doctor.


+100 points

What is Specialty Care / Specialist

200

Often abbreviated as Rx, is a formal communication from a physician or other registered healthcare professional to a pharmacist. It authorizes the pharmacist to dispense a specific prescription drug for a specific patient


+200 points

What is Prescription

200

○  A small, fixed amount a patient directly pays a provider for specific services.

○ Amount represented in dollar amount ($).

What is Copayment

300

When the same type of commercial plan is collectively purchased by a group of people. Is usually purchased by employers for their employees. 


+100 points 

What is Group insurance

300

Is the organization that has contracted with a patient to pay for a patient’s healthcare services. Referred to as “Insurance Companies.”


+100 points

What is Payor

300

Is a U.S. federal government program, which pays for certain healthcare services.

It is the US’s largest health insurance program which originated from the federal law, Title XVIII of the Social Security Act.


+200 points

What is Medicare

300

HMO-POS


+100 points

What is Point of Service

300

This part of Medicare covers Hospital Insurance.

What is Part A

300

In the U.S. this a place other than a hospital that performs outpatient surgery. 

In here (in and out) surgery center, you may stay for only a few hours, or for one night (less than 24 hours.)


+200 points

What is Ambulatory Surgical Center

300

These are prescription drugs that has the same active-ingredient formula as a brand name drug. Usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.


+100 points

What is Generic drug

300

○ A fixed percentage a patient pays for services received after a deductible and/or applicable copayment have been paid; the insurance company pays the remaining percentage.

○ Amount tepresented in percent (%).

What is Coinsurance

400

When a commercial insurance is purchased by an individual. People who are self-employed would purchase this type of policy.

What is Individual insurance

400

A written and/or verbal request from a member, authorized representative or a provider to reconsider the initial determination.


+200 points

What is Appeal

400

What is CMS?


+300 points

What is Centers for Medicare and Medicaid Services

400

What is PPFS? 

What is Private Fee for Service

400

This part of Medicare covers Medical Insurance.

What is Part B

400

This is a special way of caring for people who are terminally ill, and for their family. 


+200 points

What is Hospice

400

Are safe and effective for use by the general public without a doctor’s prescription.


+150 points

What is Over the counter (OTC)

400

The amount a member is required to pay out-of-pocket during a calendar year for covered Part A (Hospital Insurance) and Part B (Medical Insurance) services.

What is Maximum Out of Pocket
(MOOP)

500

Period of time beginning on the Plan anniversary date of any year and ending on the day before the same date of the following year.


+100 points

What is Plan Year

500

Notification to an insurance company that payment of an amount if due under the terms of a policy.


+100 points

What is Claim

500

Insurance providers use this to make sure that a specific medical service is really needed and worth the cost.


+200 points

What is Authorization

500

A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services.


+250 points

What is Skilled Nursing Facility (SNF)

500

This part of Medicare covers both Hospital and Medical plus additional benefits.

What is Part C

500

This is a way of caring for people in their own home rather than going to a facility.  


+100 points

What is Home care services

500

These are drugs marketed under a propriety, trademark-protected name

What is Brand name drug

500

The actual dollar amount charged by a physician or other provider for medical services rendered, as distinguished from the allowable charge.

What is Charge Amount