Health Insurance Key Terms 2025

Vocabulary flashcards covering key health insurance terms from the provided notes.

Adjustment

Credit entry that decreases the balance owed to the medical office; may result from insurance, professional discounts, write-offs, or correcting bookkeeping errors.

Allowed Amount

Maximum amount an insurer will pay for a given service.

Authorization

Consent to release medical information (authorization to release medical information).

Claim (HCFA-1500)

Standard claim form designed by CMS to submit physician services for third-party payment; the paper claim form used to bill Medicare FFS contractors when a paper claim is allowed.

Coding

Process of assigning codes to diagnoses and procedures to communicate with carriers and collect data for national and international purposes.

Coinsurance

Percentage of a service cost the patient pays after the deductible has been met.

Copayment

Flat fee due at the time of service.

CPT

Current Procedural Terminology; a numerical listing of procedures used for standardized identification, published by the American Medical Association.

Deductible

Amount paid by the patient before the insurer begins to pay.

EOB

Explanation of Benefits; a description of the insurer's payment and patient responsibility for a claim.

HEDIS

Health-care Effectiveness Data and Information Set; a collection of performance measures used to evaluate managed care plans.

ICD-10

Codes describing the patient's disease or condition; used to establish medical necessity for services and procedures.

Insurance Payer

The person or organization that pays the claim (also called the payer).

Premium

Monies paid for an insurance contract.

Provider

The person who oversees a patient’s health care (e.g., physician, physician assistant, or nurse practitioner).

Referral

Sending a patient to a provider of a different specialty for treatment beyond the initial practitioner’s scope.

Subscriber

The person who is insured; the policyholder.