Chapter 7 Flashcards
Case management
Where medically qualified staff working for the insurer manage claims against the most usual procedure for the particular condition
Claim form
Used on contentious claims, dental and health cash plans and for long-term protection plans
Claims assessment
Insurers become involved in determining the need for treatment by pre-authorising treatment
Dental claims
For dental insurance, a receipt from the dentist it’s required. For captation plans, no claim is required unless for an insured event
Direct settlement
Insurers use direct settlement to pay those who provide medical treatment and services to their customers
Electronic billing
Hospitals and specialist record details of a claim along with their costs or fee and forward it electronically to the insurers claim system to be processed
Gatekeeper
GP acts as a gatekeeper to hospital services and will first decide whether the patient needs a referral to a specialist to stop unnecessary treatment
Impairment codes
Code for a medical condition
Managed care
Aims to extend early intervention in the decisions surrounding medical care to ensure all procedures undertaken are clinically necessary and that alternative and less expensive treatments are also considered
Payment determination
After the validity of a claim is established, the amount to be paid, and to whom it should be paid to is determined
Pricing agreements
Insurance negotiate with hospitals for each bed category, procedure, diagnostic and consumable, with prices fixed against mutually agreed limits
Procedure code
Code for procedure
Recognised specialist
A person having knowledge and expertise, relevant to the injury or illness to which the treatment relates to
Session basis
Session is determined as a notional half day. Consultants receive payment for the session regardless of the number of patients seen
Third-party claims
Some benefits may be underwritten by third-party insurers, such claims may be handled wholly, or partly by the third-party
