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WHEN A PHYSIAN AGREES TOTREAT MEDICAID PATIENTSALSO AGREES TO ACCEPT THEESTABLISHED MEDICAIDPAYMENT FOR COVEREDSERVICES.
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FORM GIVEN TO PATIENTS BYPROVIDER WHEN A
PROCEDURE/FEE FOR SERVICEWILL NOT BE COVERED BY
MEDICARE
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THE AMOUNT THAT IS THEMOST THE PAYER WILL PAYANY PROVIDER FOR EACHPROCEDURE OR SERVICE. THEPAYERS PAYMENT IS BASED ONTHIS ALLOWED CHARGE
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A FORM THE PATIENT SIGNS"ASSIGNING" OR ALLOWINGTHEIR HEALTH INSURANCE
BENEFITS TO BE PAIDDIRECTLY TO THE PROVIDER
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A RULE THAT STATES THEINSURANCE POLICY OF A POLICYHOLDER WHOSE BIRTHDAYCOMES FIRST IN THE YEAR IS TOBE THE PRIMARY PAYER FORALL DEPENDENTS
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BLUE CROSS BLUE SHIELD IS A NATIONWIDE FERERATION OF NONPROFIT ANDFOR PROFIT SERVICE ORGANIZATIONSTHAT PROVIDE PREPAID HEALTH CARESERVICES TO SUBSCRIBERS; BLUE CROSSCOVERS MEDICAL BILLS (DOCTOR;S VISITS)AND BLUE SHIELD COVERSHOSPITALIZATION
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A PAYMENT STRUCTURE INWHICH A HEALTH
MAINTENENCE ORGANIZATIONPREPAYS AN ANNUAL SET FEEPER PATIENT TO A PHYSICIAN
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THIS IS FIXED PREPAYMENT FOR EACHPLAN MEMBER IN CAPITATION CONTRACTSTHAT IS DETERMINED BY THE MANAGEDCARE PLAN THAT INITIATES CONTRACTSWITH PROVIDERS. THE PROVIDER LISTSTHE SERVICES AND PROCEDURES THATARE COVERED BY THE CAP RATE.
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WHAT IS THE CIVILIAN HEALTH AND MEDICALPROGRAM OF THE VETERANSADMINISTRATION. A TYPE OF INSURANCE THATCOVERS THE HEALTH CARE EXPENSES OFDEPENDENTS OF VETERANS WITH SERVICECONNECTED PERMANENT DISABILITIES. ALSOCOVERS THE SURVIVING DEPENDENTS OFVETERANS WHO DIE IN THE LINE OF DUTY ORAS A RESULT OF A SERVICE CONNECTEDDISABILITY
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A GROUP THAT TAKESNONSTANDARD MEDICALBILLING SOFTWARE FORMATSAND TRANSLATES THEM INTOTHE STANDARD EDI(ELECTRONIC DATAINTERCHANGE) FORMAT
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CENTERS FOR MEDICARE ANDMEDICADE SERVICES IS ACONGRESSIONAL AGENCY DESIGNEDTO HANDLE MEDICARE ANDMEDICAID INSURANCE CLAIMS. ITWAS FORMERLY KNOWN AS THEHEALTH CARE FINANCINGADMINISTRATION (HCFA)
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UNIVERSAL CLAIM FORM THATIS SUBMITTED TO INSURANCECARRIERS FOR PAYMENT OF
THE INSURED'S MEDICAL FEES
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AMOUNT A PATIENT HAS TOPAY AT TIME OF SERVICE
DICTATED BY THE MANAGEDCARE CONTRACT (HMO, PPO,
OR POS)
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THIS IS WHEN PAYERS HAVE ANESTABLISHED FIXED FEE SCHEDULEWITH PARTICIPATING PHYSICIANSTHE TERMS FOR THE PLANDETERMINE WHAT PERCENTAGE OFTHE CHARGES IF ANY THE PATIENTOWES AND WHAT PERCENT THEPAYER COVERS.
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A NATIONALLY UNIFORMCONVERSION FACTOR IS A DOLLARAMOUNT USED TO MULTIPLY THERELATIVE VALUES TO PRODUCE APAYMENT AMOUNT. IT IS USED BYMEDICARE TO MAKE ADJUSTMENTSACCORDING TO CHANGES IN THECOST OF LIVING.
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COMMON PROCEDURALTERMINOLOGY CODES - A SET OFNUMBERS/LETTERS THATCORRESPOND TO COMMONPROCEDURE - THIS CODE IS ON THEENCOUNTER FORM AND ISTRANSPOSED TO THE INSURANCECLAIM FORM
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A FIXED DOLLAR AMOUNTTHAT MUST BE PAID (YEARLY)
BY THE INSURED BEFOREEXPENSES ARE COVERED BY
THE INSURANCE
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WHAT OLDER OR DISABLED PATIENTS WHOHAVE MEDICARE AND WHO CAN NOT PAY THEDIFFERENCE BETWEEN THE BILL AND WHATMEDICARE PAYS MAY QUALIFY FOR MEDICAREMEDICAID. IN SUCH CASES MEDICARE IS THEPRIMARY PAYER.; MEDICAID PAYS THEREMAINDER OF THE BILL. THE PATIENT ISNEVER BILLED FOR A BALANCE UNLESS THESERVICE IS A NON-COVERED SERVICE.
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THE INSURANCE THATPROVIDES A MONTHLY,PREARRANGED PAYMENT TOAN INDIVIDUAL WHO CAN NOTWORK AS A RESULT OF ANINJURY ILLNESS OR DISABILITY
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A MEDICAL PROCEDURE THAT IS NOTREQUIRED TO SUSTAIN LIFE, BUT ISREQUESTED FOR PAYMENT TO THETHIRD PARTY PAYER BY THE PATIENTOR PHYSICIAN. SOME PROCEDURESARE PAID FOR BY THIRD PARTYPAYERS WHEREAS OTHERS ARE NOT -USUALLY NEED PREAUTHORIZATION
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WHAT IS ELECTRONIC DATAINTERCHANGE - THETRANSMITTING OF ELECTRONICMEDICAL INSURANCE CLAIMSFROM PROVIDERS TO PAYERSUSING THE NECESSARYINFORMATION
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A FORM THAT CAN BE USED AS THEORIGINAL MEDICAL RECORD OF SERVICESPERFORMED FOR A PATIENT DURING ANENCOUNTER OR OFFICE VISIT, ANDCHARGES FOR THOSE SERVICES. THE FORMCAN ALSO BE USED AS A CHARGE SLIP, ASWELL AS AN INVOICE. IT CAN ALSO BESUBMITTED WITH INSURANCE CLAIMS.
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A FORM THAT EXPLAINS THE AMOUNTBILLED, AMOUNT ALLOWED BY INSURANCECONTRACT, AMOUNT PAID BY INSURANCECARRIER/COMPANY, AMOUNT OFSUSCRIBER'S/PATIENT'S LIABILITY, ANDNOTATIONS OF ANY NON COVEREDSERVICES WITH EXPLANATIONS.
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FORMERLY INDEMNITY INSURANCE -A MAJOR TYPE OF HEALTHINSURANCE PLAN THAT REPAYSPOLICY HOLDERS FOR THE COSTS ORA PERCENTAGE OF THE HEALTHCARECOSTS REDULTING FROM AN ILLNESSOR INJURY
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A GEOGRAPHIC ADJUSTMENTFACTOR IS USED TO ADJUSTEACH RELATIVE VALUE TOREFLECT A GEOGRAPHICALAREA'S RELATIVE COSTS SUCHAS OFFICE RENTS.
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HEALTH CARE ORGANIZATION THAT ESTABLISHES ANETWORK OF PROVIDERS WHO PROVIDE SPECIFICSERVICES TO INDIVIDUALS AND THEIR DEPENDENTSWHO ARE ENROLLED IN THE PLAN. PHYSICIANS WHOENROLL WITH AN HMO AGREE TO PROVIDE CERTAINSERVICES IN EXCHANGE FOR A PREPAID FEE ORCAPITIATION PAYMENT. REFERRALS ARE NECESSARYTO SEE A SPECIALIST AND PREAUTHORIZATION ISREQUIRED FOR NON-EMERGENCY PROCEDURES
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INTERNATIONAL CLASSIFICATION OFDISORDERS/DISEASES - A CODE ORSET OF NUMBERS/LETTERS THATCORRESPOND TO PATIENT DIAGNOSIS- THEY ARE ON THE ENCOUNTERFORM AND USED FOR INSURANCECLAIMS
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WHAT IS A TYPE OF INSURANCETHAT COVERS INJURIESCAUSED BY THE PROVIDER ORINJURIES THAT OCCURED ONTHE PROVIDER'S PROPERTY
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WHAT IS A FEDERALLY FUNDEDHEALTH COST ASSISTANCE PROGRAMFOR THE LOW INCOME, BLIND, ANDDISABLED PATIENTS, FAMILIESRECIEVING AID TO DEPENDENTCHILDREN, FOSTER CHILDREN, ANDCHILDREN WITH BIRTH DEFECTS.
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NATIONAL HEALTH INSPROGRAM FOR AMERICANSOVER AGE 65 OR WHO ARE
DISABLED OR CHRONICKIDNEY PATIENTS RECEIVING
DIALYSIS38b
PPO'S, HMO'S, PRIVATE FEE FORSERVICE PLANS, AND MEDICAREMEDICAL SAVINGS ACCOUNTS THATPROVIDE MEDICARE BENEFICIARIESWITH PLAN COVERAGE CHOICES INADDITION TO THE TRADITIONALMEDICARE PLAN FOR A FEE
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PRIVATE INSURANCE THATMEDICARE BENEFICIARIES CANPURCHASE TO REDUCE THE GAPS INMEDICARE COVERAGE OR THEAMOUNT THEY WOULD HAVE TO PAYFROM THEIR OWN POCKETS AFTERRECEIVING MEDICARE BENEFITS
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PART A = HOSPITAL BENEFIT FINANCEDTHROUGH FICA -PAYS FOR UP TO A 90 DAYHOSPITALIZATION OR UP TO 60 DAYSSKILLED NURSING FACILITYPART B = COVERS A PORTION FOROUTPATIENT PROCEDURES AND SUPPLIES.THIS PART IS VOLUNTARY. PREMIUM ISBASED ON INCOME AND INCREASESANNUALLY.
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PROVIDERS (DOCTORS,SURGEONS, ETC) WHO ENROLL INMANAGED CARE PLANS. THEYHAVE CONTRACTS WITHMANAGED CARE COMPANIESTHAT STIPULATE THIER FEES
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INSURANCE PLAN THATCOMBINES FEATURES OF HMOAND PPO - REFERRALS MAY BEGIVEN IN AND OUT OF NETWORKWHICH MAY REQUIRE AGREATER COPAYMENT BY THEPATIENT
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THE PROCESS OF THEPROVIDER CONTACTING THEINSURANCE PLAN TO SEE IFTHE PROPOSED PROCEDURE ISCOVERED UNDER THEPATIENTS INSURANCE PLAN
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A MANAGED CARE PLAN THATESTABLISHES A NETWORK OFPROVIDERS TO PERFORMSERVICES FOR PLAN MEMBERS;REFERRALS NOT NEEDED TOSEE A SPECIALIST
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AN AUTHORIZATION FROM AMEDICAL PRACTICE FOR APATIENT TO HAVE SPECIALIZEDSERVICES PERFORMED BYANOTHER PRACTICE (APPROVALIS OFTEN REQUIRED FORINSURANCE PURPOSES)
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THE PAYMENT SYSTEM USEDBY MEDICARE. IT ESTABLISHESTHE RELATIVE VALUE UNITSFOR SERVICES, REPLACING THEPROVIDER CONSENSUS ONUSUAL FEES
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THE NATIONALLY UNIFORMRELATIVE VALUE UNIT IS BASEDON THREE COST ELEMENTS. THEPHYSICIANS WORK, THEPRACTICE COST (OVERHEAD) ANDTHE COST OF MALPRACTICEINSURANCE.
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THE STATE CHILDREN'S HEALTHINSURANCE PLAN. THIS PLAN ALLOWSSTATES TO PROVIDE HEALTHCOVERAGE TO UNINSURED CHILDRENAND FAMILIES WHOSE INCOMES ARETOO HIGH TO QUALIFY FOR MEDICAIDBUT ARE ALSO TOO LOW TO AFFORDPRIVATE INSURANCE.
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A GOVERNMENT PROGRAM THATPROVIDES HEALTH CARE BENEFITS FORDEPENDENTS OF MILITARY PERSONNELAND MILITARY RETIREES. THIS IS NOT ANINSURANCE PLAN BUT RATHER A HEALTHCARE BENEFIT FOR FAMILIES OFUNIFORMED PERSONNEL AND RETIREESFROM UNIFORMED SERVICES.
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INSURANCE COMPANIES BASE THEIR PAYMENTS ON AUSUAL, CUSTOMARY, AND REASONABLE FEE FOR APARTICULAR SERVICE. USUAL - PHYSICIAN'S USUAL FEEFOR A GIVEN SERVICE; THE FEE MOST FREQUENTLYCHARGED FOR THE SERVICE. CUSTOMARY -RANGE OFUSUAL FEES FOR A SERVICE CHARGED BY PHYSICIANSWITH SIMILAR TRAINING AND EXPERIENCE WHOPRACTICE IN THE SAME GEOGRAPHIC AREA.REASONABLE - FEE FOR EXCEPTIONALLY DIFFICULT ORCOMPLICATED SERVICE OR A PROCEDURE THATREQUIRES EXTRAORDINARY TIME OR EFFORT BY APHYSICIAN
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