Week 3 Flashcards
(25 cards)
Document used to notify a Medicare Beneficiary that it is either unlikely that Medicare will play or certain that Medicare will not pay for the service they are going to be provided.
Advance Beneficiary Notice (ABN):
The standard claim form designed by the centers for Medicare and Medicaid services to submit physician services for third party payments
CMS-1500:
A printed disscription of the benefits provided by the insurer to the beneficiary.
Explanation of Benefits (EOB)
A percentage that a patient is responsible for paying for each service after the deductible has been met.
Coinsurance
EPO’S are like HMO’s in that patients must use their EPO’s provider network when receiving care.
Exclusive Provider Organization (EPO):
A type of managed care operation that is typically set up as a for-profit corporation with salaried employees.
Health maintenance Organization (HMO):
Prior approval of insurance coverage and necessity of procedure
Preauthorization:
Refers to the legal obligation of third parties to pay part or all expenditures for medical assistance.
Third party liability (TPL):
A phrase coined to indicate payment of services rendered by someone other than the patient.
Third party reimbursement:
The person who has been insured
Subscriber
A joint funding program by federal and state governments, for the medical care of low income patients
Medicaid
For individuals over the age of 65 or those who are disabled
Medicare
A type of insurance plan that has the least amount of structural guidelines for patients to follow.
Indemnity-type insurance
An organization of physicians who network together to offer discounts to purchasers of health care insurance.
Preferred Provider Organization (PPO)
A condition that exists along with the primary diagnosis of a patient.
Comorbidity
A list of procedures performed in medical practice
Current Procedural Terminology (CPT)
Codes that identify products, supplies, and services
HCPCS level 2 codes
Coding markers that inform third party payers that circumstances for that particular code have been altered
Modifiers
The name of the standard unique health identifier for health care providers.
National Provider Identifier (NPI)
Exists when a patient is covered under more than one insurance.
Secondary Insurance
A claim that is automatically forwarded from Medicare to a secondary insurer after Medicare has paid its portion of a service.
Crossover Claim
A private or public company that often serves as the middleman between physicians and billing groups
Clearinghouse
Federal agency within the U.S. Department of Health and Human Services (HHS)
Centers for Medicare and Medicaid Services (CMS)
The reason a patient is receiving care.
Diagnosis
