DHMP Complete Acronym Dictionary and Insurance Terminology

These flashcards encompass key acronyms and terms related to the DHMP and insurance terminology as presented in the lecture notes.

DHHA

Denver Health & Hospital Authority, the parent organization over Denver Health and DHMP.

HMO

Health Maintenance Organization, a plan requiring members to stay in-network.

POS

Point of Service, a flexible plan allowing some out-of-network care.

LOB

Line of Business, the type of insurance product.

Copay

A flat fee a member pays at a visit.

Deductible (DED)

Amount paid by a member before insurance begins paying.

Coinsurance (COINS)

Percentage paid after the deductible is met.

MOOP / OOPM

Maximum Out-of-Pocket, the most a member will pay in a year.

EOB

Explanation of Benefits, a breakdown of what was billed and covered.

MA

Medicare Advantage, private Medicare plans administered by DHMP.

EPSDT

Early Screening, Diagnosis & Treatment, special required benefits for children.

CMS

Centers for Medicare & Medicaid Services, the federal agency overseeing Medicare.

PBM

Pharmacy Benefit Manager, a vendor managing drug benefits.

NPI

National Provider Identifier, a unique ID number for providers.

APPEALS & GRIEVANCES

Department reviewing complaints and denials.

CRM

Customer Relationship Management, Microsoft Dynamics used for member/provider records.

ICD-10

Diagnosis Codes that describe medical conditions.

Eligibility

Whether someone qualifies for a plan based on various factors.

Open Enrollment

A specific time of year when people can sign up or change health plans.

Referral

A written order from a PCP that allows a member to see a specialist.

Claim

A bill submitted by a provider to the insurance company for payment.