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Assignment of benefits
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Authorization for insurance reimbursement to be made to the provider of health service rather than the insured individual
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Assignment of benefits
Authorization for insurance reimbursement to be made to the provider of health service rather than the insured individual
Benefit
the amount of money paid for a covered service under a health insurance plan
Birthday rule
If both parents of a child have a family health plan, the insurance plan of the parent whose birthday comes earlier in the year is defined as the primary insurance plan covering the child. The insurance of the other parent becomes secondary insurance
Capitation
A method of paying for insurance in which a fixed amount is paid to the provider per member for a specific time period regardless of the amount of care provided
Carrier
An insurance company
CHAMPVA
A government health insurance program that covers dependants of military veterans with service connected disabilities
coinsurance
A percentage of the allowed charge for health services, which the patient is responsible for paying
Coordination of benefits
Rules followed by insurance companies so that no claim is reimbursed at more than 100% of the charges
Co-payment
A fixed amount of money that the patient must pay for any health care service
Crossover claim
An insurance claim for an individual who is covered by Medicare and Medicaid. After review by the Medicare fiscal intermediary, the claim is automatically sent to Medicaid
Deductible
An amount of money that an insured person must pay annually before health services are covered by the insurance plan
Diagnosis-related group (DRG)
A system to determine Medicare reimbursement for a hospital stay on the basis of the pt Dx
Explanation of benefits (EOB)
A statement issued by the insurance company explaining reimbursement for specific procedures
Fee-for-service insurance
Insurance reimbursement that is directly related to the services provided and the amount charged by the provider
Fiscal intermediary
An insurance company that contracts to review Medicare claims for the Centers for Medicare and Medicaid Services
Guarantor
A person with financial responsibility for a bill who may or may not also be a patient
Indemnity
An obligation to provide compensation for loss or damage
Managed care
A movement in health care based on reducing health care costs while providing quality care. The term may be used for the techniques used to reduce costs or for the companies that pay for the care provided
Medicaid
The government insurance program for low income individuals and families that is funded both by the federal government and each individual state.
Medicare
The federal health insurance program that provides insurance coverage for the elderly, permanently disabled, and individuals with end-stage kidney disease
Premium
An amount of money paid in a given period to purchase health insurance
Primary care provider
The physician chosen by a pt to provide general medical care and also to determine and authorize additional medical services the pt may require
Primary insurance
The insurance company that must be billed first for any individual
Reimbursement
The amount paid for a procedure by insurance
Resource-based relative value scale (RBRVS)
A system to establish the Medicare fee schedule for Medicare Part B based on the service provided and the geographic location of the provider
Secondary insurance
Insurance that an individual has in addition to primary insurance
Signature on file (SOF)
an indication on the insurance claim form that the signature of the pt is maintained by the medical office to authorize submission of insurance claims
Subscriber
The person named on an insurance certificate
TRICARE
A government insurance plan that provides medical care to spouses and dependents of individuals on active duty in the military. Formerly this program was called CHAMPUS
Usual, customary, and reasonable (UCR)
A system for establishing the amount an insurance company will pay for a procedure. The reasonable charge is set by the insurance company on the basis of a physician's usual (most frequent) charge for the procedure and the customary charge of other physicians in the same geographic area
Workers' compensation
An insurance program that covers lost wages and health care costs of workers injured on the job or who suffer form work-related illnesses
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