| A | B |
|---|
| group insurance | contract between an insurance company and an employer that covers eligible employees or member |
| participating provider | provider who participates through a contractual arrangement with healthcare service contractor |
| non-participating provider | provider who does not participate through a contractual arrangement |
| basic health insurance | pays for hospital room and board and inpatient care |
| major medical insurance | treatment for long, high-cost illnesses or injuries |
| comprehensive insurance | combination of basic and major health insurance |
| premium | set amount that is paid to the insurance company periodically to cover the cost of insurance |
| deductible | out-of-pocket expense that must be paid by beneficiary before insurance company will cover procedures |
| commercial health insurance | "private" health insurance |
| health insurance exchange | set of state-regulated and standardized healthcare plans from which individuals may purchase coverage that is eligible for federal subsidies |
| Employee Retirement Income Security Act of 1974 | self-insured plans that set minimum standars for pension plans in private industry |
| third-party administrators | administrative services organizations that manage and pay claims |
| stop loss insurance | protects the insurer from devastaing effect of exhessive medical claims by limiting what insurer has to pay |
| carve-out | elimiates certain specialty service coverage under healthcare policy |
| vision, dental and prescription drug coverage | supplemental coverage |
| preferred provider organization | members have freedom to select any provider they choose |
| Medicare administrative contractors | handle Medicare financial claims, consulting, and provide communication between providers |
| point-of-service | combines both HMO and PPO |
| explanation of benefits | describes details of how the claim was adjudicated by insurance company |
| electronic remittance advice | 5010 ERA |
