Health Insurance Terminology

A set of vocabulary flashcards that cover key terms related to health insurance.

Allowed Amount

The maximum amount an insurance company will pay for a medical service.

Beneficiary

The person who receives health insurance benefits.

Advance Beneficiary Notice (ABN)

A form telling a patient Medicare may not pay for a service and they may have to pay themselves.

Assignment of Benefits

Permission for insurance to pay the doctor directly instead of the patient.

Capitation

A payment system where providers receive a fixed amount per patient each month.

Coinsurance

The percentage of costs the patient pays after meeting the deductible.

CMS

Centers for Medicare and Medicaid Services – The federal agency that manages Medicare and Medicaid programs.

Co-payment

A fixed amount a patient pays at the time of a visit or service.

Claim

A request sent to an insurance company asking for payment of services provided.

Coordination of Benefits (COB)

Determines which insurance pays first when a patient has more than one plan.

Clearinghouse

A company that checks medical claims for errors before sending them to insurance companies.

CMS-1500

The standard form used to bill insurance for outpatient medical services.

Deductible

The amount a patient must pay before insurance starts paying.

Dependent

A family member covered under another person’s insurance plan.

Elective Procedure

A non-emergency medical procedure planned in advance.

Eligibility

Verification that a patient has active insurance coverage.

Exclusive Provider Organization (EPO)

A health plan that only covers services from doctors within its network.

Explanation of Benefits (EOB)

A statement showing what insurance paid and what the patient owes.

Fee-for-Service

Payment made for each individual service provided.

Fee Schedule

A list showing approved payment amounts for medical services.

Gatekeeper

A primary care provider who controls referrals to specialists.

Flexible Spending Arrangement (FSA)

A pre-tax account used to pay medical expenses.

Group Practice Insurance (GHI)

Insurance coverage provided through an employer or organization.

Health Insurance Exchange (HIE)

A marketplace where individuals can compare and purchase health insurance plans.