CHAPTER 12 HEALTH INSURANCE ESSENTIALS

beneficiary

a designated person who receives funds from an insurance policy.

capitation

a payment arrangement for healthcare providers.

claim

a formal request for payment from an insurance company for service provided.

explanation of benefits (EOB)

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 patients financial responsibilities.

fee schedule

a list of fixed feed for services.

gatekeeper

the primary care provider, who is in charge of a patients treatment. Additional treatment, such as referrals to a specialist, must be approved by the gatekeeper.

health insurance exchange

an online marketplace where people can compare and buy individual health insurance plans. State health insurance exchanges were stablished as part of the affordable care act.

indigent

poor, needy, impoverished

online insurance web portal

an online service provided by various insurance companies that allows providers to look up a patients 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 carriers in which the provider obtains permission to perform certain procedures or services.

premium

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

preexisting condition

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

provider network

an approved list of physicians, hospitals and other providers.

Qualified Medicare Beneficiaries (QMB’s)

Low-income Medicare patients who qualify for Medicaid for their secondary insurance.

referral

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

resource-based relative value system(RBRVS)

a system used to determined how much providers should be paid for services provided. It is used by Medicare and many other health insurance companies.

third-party administration (TPA)

an organization that processes claims and provides administrative services for another organization. Often used by self-funded plans.

utilization management

a decision making process used by managed care organization to managed healthcare costs. It involves case-by-case assessment of the appropriateness of care.

waiting period

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