Insurance Basics
What is the term for the amount you pay every month to keep your health insurance active?
What is a premium?
This is the amount you must pay out-of-pocket before your insurance kicks in.
What is a deductible?
Which type of plan requires members to use a network of doctors and get referrals for specialists?
What is an HMO (Health Maintenance Organization)?
What is the form submitted to the insurer to request payment for services?
What is a claim?
What should you always do before placing a caller on hold?
What is ask for permission and explain the reason?
What is the amount you must pay before your insurance starts covering costs?
What is a deductible?
This limit is the maximum amount you’ll pay in a year.
What is the out-of-pocket maximum?
This type of plan allows more flexibility to see out-of-network providers but at higher costs.
What is a PPO (Preferred Provider Organization)?
What do we call the explanation sent by insurers detailing what was covered and what was not?
What is an EOB (Explanation of Benefits)?
Name one phrase to show empathy to a frustrated member.
What is “I understand how frustrating this must be for you”?
What is the part of the cost you pay after the deductible, usually a percentage?
What is co-insurance?
The list of drugs covered by your insurance plan is called this.
What is a formulary?
This type of government insurance is for people aged 65 and older.
What is Medicare?
What is it called when a claim is rejected because it lacks information or has errors?
What is a denied claim?
How can you confirm that a member understands what you explained?
What is “Can you please repeat back what we discussed to make sure I was clear?”
What is the fixed fee paid for healthcare services like doctor visits?
What is a co-payment?
Services that must be covered under the ACA are called this.
What are essential health benefits?
This government program provides insurance for low-income individuals and families.
What is Medicaid?
What is the term for the maximum amount an insurer will pay for a covered service?
What is the allowable amount?
If a member is confused about their EOB, what should you do first?
What is walk them through the document line by line?
What is the annual maximum amount you must pay before insurance covers 100% of expenses?
What is the out-of-pocket maximum?
This period allows changes to your health plan each year.
What is open enrollment?
This type of insurance supplements employer or private insurance and covers costs like co-payments and deductibles.
What is gap coverage or supplemental insurance?
What is the process of reviewing and updating patient coverage details before billing?
What is verification of benefits?
What’s one way to de-escalate a call with an angry member about denied claims?
What is acknowledge their frustration and offer a resolution path or escalation process?