cccma ch 4 - continuity of care

copay

payment made by a beneficiary/pt in addition to that made by an insurer.

deductible

a specified amount of money that the insured must pay before an insurance company will pay a claim

provider network

all doctors, specialists, hospitals, and other providers who agree to provide medical care to HMO or PPO members under the terms of the insurance company

referral

recommendation of a medical or paramedical professional

HMO

is a referral usually necessary for HMO, PPO, or both?

PCP

primary care provider

COC

continuity of care

TOC

transition of care

patient encounter form

summary based on pt/dr interaction

ABN

an acknowledgment that testing is desired and approved, even though Medicare may not pay

POA

Power of Attorney

HMO

Health insurance plan that’s private or provided by employer

PPO

health insurance plan that is managed-care based

5

required parts of a referral

Superbill/encounter form

list of diagnosis, charges, and procedures

CMS-1500 aka HCFA-1500

claim form used by non-institutional providers with ICD-10 and CPT codes

CM 1450 aka UB-04

claim form used by institutional providers with ICD and other revenue codes