NHA CCMA Health care systems and settings (Insurance fundamentals)

Third party payers

organizations that pay for healthcare services on behalf of the patients.

Deductibles

Montetary amount patients must pay to the provider for health care services before the services (insurance) begins to pay.

Certificate of coverage

Letter that documents the nature and length of coverage with the plan.

Formulary

A list of drugs approved for coverage. It is subdivided into two or more tiers with each tier having a different level of coverage.

Eligibility

To determine if a patient is qualified to receive coverage/paid insurance policy guidelines.

Insurance claims

Bills that medical offices send to insurance companies on behalf of patients for medical services.

Assignment of benefits

When patients signs this it authorizes the insurance company to pay directly to the provider.

Fee schedule

A list of charges for each services they provide such as a physical exam or flu shot.

Verfication of benefits (VOB)

The process to determine the patient's eligiblity

Point of service (POS)

Offers a primary HMO provider network & a secondary ppo provider network. Allowing patients to choose which plan to use at the time of the service.

Allowed amount

The amount that insurance companies consider to be an appropriate fee.

Dependents

Family members may include a spouse or unmarried domestic partner, children or step children.

Medical necessity

The process of establishing the medical need for services

Group health insurance

A policy offered to a group of people in which the risk or cost of insurance is spread across everyone equally.

Waiting period

Insured for the 24 months before joining the new plan.

Denied claim

A claim that was processed and found to be ineligible for payment.

Out of pocket expenses

Medical expenses that patients are personally responsible to pay.

Health insurance exchange (HIE)

Organizations that offer a choice of health insurance plans certify the plans that participate and provide consumer information regarding options.

Coinsurance

A fixed percentage of charges that patients pay.

Current Procedural Terminology (CPT)

A system of codes established by the american medical association to identify specific medical, surgical and diagnostic services.

Individual health insurance policies

Individuals who buy directly through insurance carriers.

Premium

Paid in monthly payments for the next month's coverage

Emergency procedures

Those that must be performed immediately in order to save a patient's life, limb or vision

Copayments

Fixed dollar amount that patients pay at the time of the service

Indemity

To pay for the loss experienced by another person

preventive care

Annual preventive care examinations, immunizations and screening test.

Ancillary service

Supplemental riders for prescription drugs, vision, dental and alternative care.

Disease specific

Supplemental insurance for specific chronic or terminal illness such as cancer.

Hospital

Care such as room and board, facility fees for services including radiology and lab.

Physician

For hospital visits, office visits and nonsurgical procedure.

Surgical

Surgical procedures performed in a hospital, doctor office or outpatient surgical center

Catstrophic

Emergency safety net to protect against unexpected high cost medical services only.

Self insured plan

Offered by large employers or unions that rather than purchasing a group health insurance set aside money in a reserve fund and pay for employee medical expenses from the fund

Health insurance

A contract between an insurance carrier and the person who owns the insurance policy known as the policyholder, member, insured and subsriber.

Fee-for-service (FFS)

Allowed patients to seek care with any covered healthcare provider for any covered services.

Beneficiency

Those who are covered by government policies, refers to the individual who qualifies for the program.

Elective procedures

Can be scheduled at a later time and induce a broad range of procedures such as back surgery.

Private health insurance

Coverage for healthcare services offered by private corporations such as Aetna, cigna or united state healthcare & not-for-profit organizations such as blue cross/blue shield.

Consoildated omnibus reconciliation act (CORBA)

Requires employers to extend health care insurance coverage at group rates, up to 18 months.

Pre-existing conditions

Any condition a patient was diagnosed with or treated for including receiving medication before beginning coverage with a new insurance.