chapter 12 health insurance

beneficiary

a designated person who receives funds from an insurance policy

capitation

a payment arrangement for healthcare providers in which providers receive a per person/ per month payment regardless of how often the provider sees the patient

claim

a formal request for payment from an insurance company for services provided

explanation of benefits

a document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, and the patient financial responsibility

fee schedule

a list of fixed fees for services

gatekeeper

the primary care provider who is in charge of a patient’s treatment.

health insurance exchange

an online marketplace where people can compare an buy individual plans.

indigent

poor needy impoverished

online insurance web portal

an online service provided by various insurance companies that allow providers to look up a patient’s insurance benefits, eligibility, claims status, and explanation of benefits

policy

a written agreement between two parties in which one party (the insurance company) agrees to pay another party (the patient) if certain specified circumstances occur

preauthorization

a process required by some insurance carries in which the provider obtains permission to perform certain procedures or services

preexisting condition

a health problem that was present before new health insurance coverage started

premium

the amount paid or to be paid by the policyholder for coverage under the contract, usually in periodic installments

provider network

an approved list of physicians, hospitals, and other providers

referral

an order from a primary care provider for the see a specialist or to get certain medical services

waiting period

the length of time a patient waits for disability insurance to pay after the date of injury

insurance

something that is purchased to help protect against loss or harm from specified circumstances

subscriber

the person responsible for the payment of the premium

deductible

a set dollar amount that the policyholder must pay before the insurance company starts to pay for services

co-insurance

after the deductible has been met, the policyholder may need to pay a certain percentage of the bill, and the insurance company pays the rest

copayment

a set dollar amount that the policyholder must pay for each office visit

two types of health insurance plans in the US

government health insurance plans

private health insurance plans

medically necessary

services are those that are proper and needed for the diagnosis or treatment of the medical condition

elective procedures

are medical procedures that are not deemed medically necessary, such as a facelift or another cosmetic procedure

preventive care

includes services provided to help prevent certain illnesses or that lead to an early diagnosis

what u need to qualify for government health insurance

age, income, government occupation, health condition

Medicare

a federal health insurance program that provides healthcare-coverage for individuals who are age 65 or older. people who are disabled, and patients who have been diagnosed with end-stage renal disease

Medicaid

Medicaid is the government program that provides medical care for the indigent

a regular referral

which usually takes 3 to 10 working days for review and approval

a urgent referral

which usually takes about 24 hrs for approval this type of referral is used when an urgent but not life-threatening situation occurs

a STAT referral

a STAT referral is used in an emergency situation as indicated by the provider. which can be approved online when it is submitted to the utilization review department through the providers web portal.

verification of eligibility

is the process of confirming health insurance coverage for the patient

effective date

the MA should also verify the date the insurance coverage began, and confirm that the patient will be covered on the date the medical services are provided

workers compensation

an insurance plan for individuals injured on the job or become ill due to job-related circumstances

life insurance

provides payment of a specified amount, upon the insured’s death to a designated beneficiary or to the insured’s estate

liability insurance

insurance covers losses to a third party caused by the insured

legal and ethical issues

verification of eligibility is a process that is important not only to ensure the insurance plan is valid at the time of service but also to ensure that the patients identity