| A | B |
|---|
| Medicaid | Gov't medical program, low income |
| preauthorization | HMO pt need for non emergency hospital visit |
| gatekeeper | Primary care provider, manages care/ costs |
| Diagnosis code | condtion and illnesses |
| procedure code | treatment (TX) or procedure |
| annual routine exams, immunizations | preventive care |
| ledger | financial transactions |
| HMO | regulated by federal and state law |
| % insured pays for visit | copayment |
| DX and procedure codes | how coder bills services |
| schedule of benefits | medical expenses that policy covers |
| HMO providers | network subscribers must use |
| medicare | covers pts over 65 |
| out of pocket | paid by the patients |
| individual, group or organization | types of health care entities |
| third party | govt or private insurance |
| out of network provider | not under contract with the payer |
| policyholder | pays premium |
| insurance company provides | payments for medical services |
| medical necessity | correctly identify pts condition for TX |
| physcian,patient and insurance company | parties of insurance contracts |
| PPO referrals | no need for specialists |
| fee for service plan | paid after services |
| medicare, medicaid, worker's comp | govt programs |
| premium deductible and coinsurance | met b4 indemity plan pays |
| indemity patient | may use any provider |
| HMO patient | must use network doctors |
| PPO services | discounted fees |
