Insurance and Reimbursement Key Terms

Question 1

Advance beneficiary notice (ABN)

Answer 1

medicare may not cover certain services, pt responsible for bill

Question 2

assignment of benefits

Answer 2

transfer pt legal rights to the provider to collect insurance $ / insurance payment for services will go straight to the provider instead of the patient

Question 3

balance of billing

Answer 3

billing patient for total, or total after insurance

Question 4

capitation

Answer 4

managed care plan that pays certain amount to provider over time for caring for pt

Question 5

coinsurance

Answer 5

agreed amount paid to provider by policy holder

Question 6

coordination of benefits

Answer 6

order in which multiple insurance companies pay (prevents double payments)

Question 7

copayment/copay

Answer 7

part of insurance that patient pays

Question 8

crossover claim

Answer 8

crosses over automatically from 1 coverage to another payment

Question 9

current procedural terminology (CPT codes)

Answer 9

codes used by physicians to define services provided to the patient

Question 10

deductible

Answer 10

amount pt pays before insurance begins paying

Question 11

dependent

Answer 11

spouse or children under insurance plan

Question 12

diagnosis related groups (DRGs)

Answer 12

categories used to determine reimbursements for medicare pt inpatient services

Question 13

eligibility

Answer 13

pt meets the qualifications to be covered by the insurance

Question 14

explanation of benefits (EOB)

Answer 14

statement that accompanies payment, includes date and services paid for

Question 15

health care savings account (HSA)

Answer 15

offered by employer, takes some money out of paycheck and puts into a savings account for medical use

Question 16

independent practice association (IPA)

Answer 16

independent physicians contracted with health maintenance organization to provide services to members

Question 17

Health Maintenance Organization (HMO)

Answer 17

wide range of services through contract with specific group at predetermined rates

Question 18

healthcare common procedure coding

Answer 18

assigns alphabetic and numeric code to services and items

Question 19

medicare

Answer 19

federally funded insurance for people 65+ or disabled

Question 20

medicare A

Answer 20

Portion of Medicare that deals with hospital expenses

Question 21

medicare B

Answer 21

physician fees, test, some immunization

Question 22

medicaid

Answer 22

Federal and State funded for people with low incomes.

Question 23

medi-medi claim

Answer 23

beneficiary with Medicare primary and medicaid as secondary payment. AKA crossover claim

Question 24

medicare administrative contractors (MACs)

Answer 24

process claims from providers for services rendered for medicare beneficiary

Question 25

pre-existing condition

Answer 25

medical problems existing before insurance plan’s effective date

Question 26

primary and secondary coverage

Answer 26

primary- file 1st secondary-bill remainder of charges

Question 27

centers for medicare and medicaid services (CMS)

Answer 27

mandate use of panels defined by AMA for national standardization of testing

Question 28

plan maximum

Answer 28

highest amount paid by insurance

Question 29

preferred provider organization (PPO)

Answer 29

contract with preferred healthcare provider

Question 30

remittance advice (RA)

Answer 30

medicare administration contract showing payments/ explaining reimbursment

Question 31

usual, customary, reasonable (UCR)

Answer 31

usual cost of similar services in area

Question 32

utilization review (UR)

Answer 32

checks cases to make sure bill were medically necessary

Question 33

coding

Answer 33

assignment of a number to verbal statement or description

Question 34

international classification of diseases (IDC)

Answer 34

transforming verbal description to numeric code

Question 35

nonsufficient funds (NSF)

Answer 35

no money, hot checks

Question 36

collections

Answer 36

acquiring funds that are due

Question 37

credit

Answer 37

record of a payment recieved; balance in one’s favor on an account.

Question 38

debit

Answer 38

a charge owed on an account

Question 39

day sheet/ daily journal

Answer 39

a daily record listing all financial transactions and/or patients seen

Question 40

denial

Answer 40

insurance company says they will not pay