Flashcards in Insurance Deck (121)
Access to Care
The ability and ease of patients to obtain healthcare when they need it.
A legal duty, imposed by statute or otherwise, owing by defendant to the one
Statistical analysis of a population based on its utilization of healthcare services
and demographic trends of the population. Results used to estimate healthcare plan premiums or
Complexity and severity of the patient's health/medical condition.
A trained insurance professional who specializes in determining policy rates, calculating
premiums, and conducting statistical studies.
Administrative Services Only (ASO)
An insurance company or third party administrator (TPA) that
delivers administrative services to an employer group. This usually requires the employer to be at
risk for the cost of health care services provided, which the this company/administrator processes and manages claims.
A person who handles claims (also referred to as Claims Service Representative)
A form of utilization review in which an assessment is made of the medical
necessity of a patient's admission to a hospital or other inpatient facility.
ensures that patients requiring a hospital-based level of care and length of stay appropriate for the
admission diagnosis are usually assigned and certified and payment for the services are approved.
Ambulatory Payment Classification (APC) System
An encounter-based classification system for
outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and
ambulatory surgery. Payment rates are based on categories of services that are similar in cost and
The formal process or request to reconsider a decision made not to approve an admission
or healthcare services, reimbursement for services rendered, or a patient's request for postponing the
discharge date and extending the length of stay.
The amount Medicare pays a physician based on the Medicare fee schedule.
Physicians may bill the beneficiaries for an additional amount, subject to the limiting charge allowed.
Assignment of Benefits
Paying medical benefits directly to a provider of care rather than to a
member. This system generally requires either a contractual agreement between the health plan and
provider or written permission from the subscriber for the provider to bill the health plan.
Assumption of Risk
A doctrine based upon voluntary exposure to a known risk. It is distinguished
from contributory negligence, which is based on carelessness, in that it involves a comprehension
that a peril is to be encountered and a willingness to encounter it.
The term "assurance" is used more commonly in Canada and Great Britain.
The term "insurance" is the spreading of risk among many, among whom few are likely to suffer loss.
The terms are generally accepted as synonymous.
An individual eligible for benefits under a particular plan. In managed care
organizations they may also be known as members in HMO plans or enrollees in PPO plans.
The sum of services for which a health plan, government agency, or employer
contracts to provide. In addition to basic physician and hospital services, some plans also cover
prescriptions, dental, and vision care.
The amount payable by an insurance company to a claimant or beneficiary under the
claimant's specific coverage.
A fixed amount of money per-member-per-month (PMPM) paid to a care provider for
covered services rather than based on specific services provided. The typical reimbursement method
used by HMOs. Whether a member uses the health service once or more than once, a provider who
is capitated receives the same payment.
An insurance company formed by an employer to assume its workers' compensation and
other risks, and provide services.
The insurance company or the one who agrees to pay the losses. It may be
organized as a company, either stock, mutual, or reciprocal, or as an Association or Underwriters.
Services excluded from a provider contract that may be covered through arrangements
with other providers. Providers are not financially responsible for these services of their contract.
Rate of reimbursement that packages pricing for a certain category of services.
Typically combines facility and professional practitioner fees for care and services.
The dollar amount stated in a claim file which represents the estimate of the amount
A general class of insurance and workers' compensation insurance.
Certification or Authorization
The approval of patient care services, admission, or length of stay by a health benefit
plan (e.g., HMO, PPO) based on information provided by the healthcare provider.
A request for payment of reparation for a loss covered by an insurance contract.
One who seeks a claim or one who asserts a right or demand in a legal proceeding.
Claims Service Representative
A person who investigates losses and settles claims for an
insurance carrier or the insured. A term preferred to adjuster.
Clinical Review Criteria
The written screens, decision rules, medical protocols, or guidelines used
to evaluate medical necessity, appropriateness, and level of care.