CMA

Policy

A course of action that should be taken every time a certain situation occurs

Benefits

In the insurance industry, the services or items covered in an insurance policy

Claim

In the insurance industry, a request for payment of covered benefits

Dependent

In health insurance and individual who receives insurance benefits due to a relationship to the subscriber, i.e. child or spouse

Guarantor

In healthcare, the person who is financially responsible to pay a medical bill

Premium

In the insurance industry, a monthly payment made to purchase insurance coverage

Deductible

In the insurance industry, an amount that must be paid for covered services by the subscriber before insurance benefits are paid

Copayment

In healthcare insurance, a set amount that must be paid by the subscriber for a covered service

Coinsurance

A percentage of charges that must be paid by the subscriber for a covered service

Affordable care act/patient protection

A federal law enacted in 2010 with the goals of making insurance affordable to more people expanding Medicaid coverage and supporting care practices that improved patient health and lower cost

Out of pocket maximum

A limit on the total amount, a subscriber must pay each year for covered services

Explanation of benefit(EOB)

A summary of coverage provided by an insure to the subscriber, and the healthcare provider after an insurance claim is made, including what portion of the charges are covered by insurance and what portion must be paid by the patient

Remittance advice RA

Statement of a document provided by an insurer to a healthcare provider summarizing a health insurance claim, including charges that may have been billed what portions are covered by insurance and what portions must be paid by the patient

Allowable amount

A standard fee for a treatment service or supply set by an insure providers contracted with an insure are obliged to accept this amount as payment

Rider

Something added to an insurance policy that changes the terms of the policy

Indemnity plan

A type of health insurance in which the subscriber can choose any provider or facility for healthcare and receive reimbursements based on build cost as long as the charges are considered, usual customary, and reasonable sometimes called a fee for service plan

Managed care

A system or strategy of managing healthcare in a way that controls cost

Gatekeeper

Term sometimes used to describe a primary care provider, refers to the providers role in managing a patient’s access to healthcare services

HMO

A form of health insurance in which the cost of care is covered only when a person uses a particular doctor or group of doctors except in case of emergency, seeing specialist generally require referrals from a primary care provider

Capitation fee

A form of managed care payment in which a provider receives a flat fee for each patient each month rather than receiving a payment for each service provide provided

PPO preferred provider organization

A managed care plan in which patients are encouraged, but not required to see providers in a provider network established by the insurance carrier

Exclusive provider organization

a type of managed care plan that requires the patient to see network providers for all health services

Point of service plan

A type of managed care plan that requires the patient to choose a primary care provider and see specialists in the provider network with a referral. Patient may see providers outside the network, but will pay more to do so.

Medicare

A federal health insurance program for people who are 65 or older, have certain disabilities or permanent kidney failure, or are ill and cannot work

Medicare administrative contractors MAC

Private insurers contracted to manage Medicare claims in a specific geographical region

Medicaid

A medical assistance program for people who have low income, as well as for people with disabilities

Children’s health insurance program CHIP

A government program providing low, cost health insurance to families and pregnant woman with a low income

TRICARE

The health insurance program for the US military

Primary insurance

The first insure to pay benefits when a patient is covered by more than one policy

Secondary insurance

In cases in which a patient is covered by more than one insurance policy, the ensure that pays on the remaining balance after the primary insurance benefits have been paid

Coordination of benefits COB

Determination of how a claim should be paid when more than one ensure covers a patient

Assignment of benefits

Permission granted by a subscriber for insurance benefits to be paid directly to the provider for services provided

National provider identifier NPI

A 10 digit number, unique to each healthcare provider and used in the filing of insurance claims

Direct billing

In healthcare and arrangement in which a provider or facility submit claims directly to an insurer on behalf of a patient

Clearing house

A company that specializes in reviewing insurance claims for errors and submitting claims to ensures on behalf of a provider/facility

ABN

A Medicare form used to inform a patient that a procedure or service will not be covered by Medicare benefits, and that the patient is financially responsible if the service is provided

international classification of diseases

A coding system used to track morbidity and mortality the basis of coding systems used to identify diagnosis in patient procedure procedures for insurance purposes

Billable

In healthcare a code with adequate detail to present to an ensure as part of a claim

Encounter

In healthcare and interaction between a patient and a provider that may be billed/generate an insurance claim

CPT code

A code established in the American medical associations, current procedural terminology manual, which is the standard coating set used to bill insurance for more outpatient care

Bundled code

A code used to submit an insurance claim for two or more procedures that frequently occur together

HCPCS

An additional coding system for procedures, services equipment, and supplies not included in the CPT manual

Down code

In healthcare coding may refer either to a provider, submitting a claim, using a code for a lower level of service than what was actually provided or to an ensure paying a claim at a lower rate than the submitted code would require

Up code

In healthcare coding inappropriately billing for a procedure or service that is more complex than what is performed or provided

Audit

In healthcare billing a review of diagnosis and procedure codes to ensure that they follow the correct guidelines maybe performed internally for quality assurance or externally as a form of inspection

Credit

Money coming in; income

Debit

Money going out; expense

Physician fee

Schedule a set list of fees charge for each type of healthcare service provided at and office/facility

Ledger

A record of all financial transactions for a business may be electronic or on paper

Billing cycle

The schedule used in a medical office to determine when patients receive bills for outstanding balances

Sliding scale

A system established to adjust physician fees based on patient’s household income patient with lower household income, may pay less than patience with a higher household

Check

A bank draft that directs funds to be taken from a bank account for payment of an expense

Interest

Money that is paid at a set percentage rate for a debt

Aging report

A report showing the length of time that has passed since a charge was posted to an account

Delinquent

In financial terms, overdue for payment

Uncollectible

With references to a medical bill, not likely to be paid providers/facilities may turn these bills over to a collection agency

Collection agency

A business that specializes in collecting old debts

Bad debt

And accounting category that may be used for bills that are deemed uncollectible

Accounts payable

A businesses expenses, which include payroll, taxes, supplies rent

Accounts receivable

A business is income, which for a medical office include patients payments, insurance payments, and interest payments

Asset

In financial terms, something that increased, the net worth of a business accounts receivable are considered part of a businesses assets

Liability

And expense or something that reduces the net worth of a business accounts payable are considered a liability

Embezzlement

A type of thief in which an employee steals from their employer

Negotiable

In banking, payable, i.e. valid check is negotiable

ABA number

A number that appears as a fraction on the upper right portion of a check, identifying the bank associated with the check riders account

Routing transit number RTN

A number associated with a bank account that identifies the financial institution where the account was opened and allows money to be moved in and out of the account

Endorse

In banking to sign or stamp the back of the check to indicate it has been accepted

Electronic funds transfer EFT

A means of moving money from one financial institution to another electronically

Purchase order PO

A request to make a purchase confirms that payment is authorized for the items ordered

Vendor

A business providing goals or services to another business or individual

Invoice

A bill or a summary of charges associated with an order from a vendor

Inventory

A record of the items present in an office/facility