| A | B |
|---|
| claim investigation | making a detailed inquiry to verify facts pertaining to a submitted claim |
| member Files | files that contain only one member's claim documents per file |
| claim processing | means to determine benefit amounts and pay, pend, or deny a claim |
| separate procedure | commonly performed as part of a larger service |
| HMO | a prepayment plan in which providers agree to charge members for their services with a fixed schedule rates |
| Claim file documentation | orderly organization and communication of important facts that can be use to furnish decisive evidence of claim handling or processing |
| primary insurance | the health insurance plan that pays its bnenfits first |
| explanation of benefits | letter form the payer indicating how a member's benefits have been applied |
| Basic benefits | paid at 100% before Major medical |
| Major medical benefits | paid after basic & subject to deductibe and coinsurance |
| accident benefits | unintentional injury which has a specific time, date and place. |
| Preadmission Testing | tests provided to a patient prior to surgery to avoid an over night stay in the hospital |
| Lifetime maximum | total dollar payments the insurance carrier will make toward the care of the member |
| Second surgical opinion | opinion provided by a second physician when one physician recommends surgery to an individual |
| credible coverage | credit given for the period of time an individual was covered by a former employer |
| carryover deductible | any amounts that the patient pays toward the deductible in the last three months of the year that will be applied towards next years deductible |
| preexisting condition | a medical condition in which a condition existed prior to the purchase of the policy |
| aggregate | Accumulating a family deductible by any family member |
| nonaggregate | family deductible which a specified number of members need to meet the indvidual deductible first before family deductible is met |
| conversion factor | a dollar amount determined for a specific service type or a particular geographic area |
| allowed amount | what the insurance company considers to be a reasonable charge for the procedure performed |
| contract | a legal and binding written document that exists between two or more parties |
| qualifying event | refers to an event which results in the loss of elegibility under the employe sponsored health plan |
| eligibility | when a person meets the qualifications that make the person eligible for converage |
| coordination of benefits | a process that occurs when tow or more plans provide coverage on the same person |
| order of benefits determination rules | standardized rules for coordination amoung health plans |
| preauthorization | to gain approval of the services that are to be performed |
| retrospective review | used to determine after discharge whether the hospitalization and treatment were medically necessary |
| fee schedule | allowable amount for that particualr procedure assigned according to the particular CPT code |
| calculating UCR | the process of determining the fee usally charged by similar providers for the same procedure in the same geographic area |
| concurrent review | determines whether the estimated length of time and scope of the inpatient stay is justified by the diagnosis and symptoms |
| utilization review | insurance carriers review the total treatment of a patient and determine whether or not the costs will be covered |
| predetermination | an estimate of maximum benefits that may be paid under the plan for the services |
| precertification | preapproval for admission on an elective, nonemergency hospitalization |
| rehabilitation facilities | specialized in long term, postsickness or post injury care |
| medical management | x-ray, and laboratory charges that are incurred to control or manage a diagnosis |
| professional component | the reading and interpreting of lab results or x-rays |
| technical component | collecton of specimen or taking of x-rays |
| hospice care | pallative care for a terminally ill patient |
| durable medical equipment | items that can be used for an extended period of time without significant deterioration |
| take home prescriptions | medications to be taken after the patient is released from the hospital |
| paramedics | specially trained emergency medical personnel who render treatment at the scene of the injury or illness |
| ancilliary expenses | miscellaneous services or supplies that are provided by the hospital which are necessary for the medical care or treatment of an individual |
| personal items | those items that are primarily for the comfort of the patient and are not medically necessary |
