Health Insurance and TOA Procedures

VOCABULARY flashcards covering types of health insurance, specific TOA policies, and insurance data entry procedures.

Medicare

A federal program providing health coverage for individuals age $65+$ or those under $65$ with a disability, regardless of income.

Supplement Insurance

A policy that picks up the remaining balance after Medicare (the Primary payer) has paid its portion.

Medicare Advantage Plan

A plan where Medicare and another insurance are combined into one card; it takes the place of standard Medicare.

UHC Dual Complete

A specific Medicare Advantage policy that TOA treats as Tenncare because of low reimbursement rates.

Medicaid (Tenncare)

A joint state and federal program providing health coverage for low-income individuals; TOA only contracts with specific MCOs and not with out-of-state MCDs.

Employer-sponsored / Commercial / PPO

Health insurance typically obtained through an employer where the cost of the monthly premium is split between the employer and employee.

Individual and Family Plans

Coverage that individuals enroll in themselves via a state/federal marketplace or insurance companies, often used by the self-employed.

HMO (Health Maintenance Organization)

A plan requiring a primary care doctor and referrals to see specialists, with no coverage for out-of-network services.

PPO (Preferred Provider Organization)

A plan that does not require the patient to name a primary care doctor or obtain a referral to see a specialist.

Tricare East (Prime policy)

A government insurance policy that requires an authorization through Humana Military.

VA CCN Optum

Coverage authorized through the VA by fax; authorizations are scheduled by team member McKalah.

BMI Insurance

Secondary insurance for college athletes that always remains secondary unless the primary payer is a government entity like Tricare or Tenncare.

BMI Insurance ID

The athlete's social security number or, if unavailable, their date of birth in the format $MMDDYYYY$ (Example: $05052020$).

Medical Claims Address

Usually a \text{PO Box #} on the back of the card for commercial insurance, except for BCBS.

Subscriber ID

The member or plan ID listed as "policy" in the Nextgen (NG) system.

Government Insurance Policy Holder Rule

For Medicare and Tenncare, the insurance is always listed under the patient, and there is no separate policy holder.

Guarantor

A required entry in Nextgen (under the Relations/Roles tab) for any patient under the age of $18$ for billing purposes.

Self-pay Restriction

A rule preventing patients with government insurance (Tricare, Medicare, or Tenncare) from opting for self-pay.