UHC - QUIZ

HIPAA

Health Insurance Portability and Accountability Act

A U.S. law designed to provide privacy standards to protect patients' medical records and other health information.

Prior Authorization

Preauthorization or Precertification

The approval from an insurance company for specific services before they are provided to the patient, to ensure coverage.

7. Claim

A request for payment that the insured or healthcare provider submits to an insurance company.

8. Denial

The refusal by an insurance company to cover a specific treatment or procedure.

9. Appeal

The process by which a patient or provider disputes a denial of coverage or payment by the insurance company.

10. Provider

A healthcare professional or organization that delivers care to patients (e.g., doctors, hospitals, clinics).

11. Network

A group of healthcare providers that have contracted with an insurance company to provide services at a discounted rate.

12. In-Network

Providers or services that are covered under an insurance plan’s network, often at lower costs to the patient.

13. Out-of-Network

Providers or services that are not contracted with an insurance plan, typically resulting in higher costs for the patient.

Co-pay

A fixed amount a patient pays for healthcare services, usually paid at the time of service.

15. Deductible

The amount a patient must pay out-of-pocket before their insurance begins to cover services.

16. Premium

The amount paid by a patient or their employer for health insurance coverage, typically monthly.

17. Coordination of Benefits (COB)

A process used by insurance companies to determine the order in which multiple insurance policies will pay for services.

Co-insurance

A percentage of costs the patient must pay for covered healthcare services after they’ve met their deductible. For example, if the plan covers 80%, the patient pays 20% (the co-insurance).

29. Balance Billing

When a provider bills the patient for the difference between what the insurance reimburses and the provider's charge. This often occurs with out-of-network providers.

18. Member ID

A unique identifier for a patient under a healthcare plan, used to track their coverage and services.

Authorization Number

A number issued by the insurance company approving a specific treatment or service.

26. Out-of-Pocket Maximum (OOP Max)

The most a patient has to pay during a policy period (usually a year) for covered healthcare services. Once this limit is reached, the insurance company pays 100% of covered services for the rest of the year.

27. Out-of-Pocket Costs

The total amount a patient is required to pay for healthcare services, which includes the deductible, co-payments, and co-insurance.