| A | B |
|---|
| Medicaid | Government-based health insurance that pays for medical assistance for individuals who are low income |
| Medicare | Federally funded health insurance provided to people age 65 or older |
| pre-authorization | Determines if procedures are medically needed |
| pre-certification | a review to looks if the procedure could be preformed in less expensive outpatient setting |
| pre-determination | a written request for a verification of benefits |
| referral | written recommendation to a specialist by the PCP |
| Formulary | Refers to list of prescription drugs covered by the insurance plan |
| Demographic | Name, DOB, Gender, SSN, Insurance ID Card |
| Birthday Rule | Health plan of the parent whose birthday comes first in the calendar year is designated a primary plan |
| Capitation | Refers to a fixed amount a providers receives |
| co-insurance | percentage a patient is responsible after deductible has been met |
| Coordination of Benefit | Determining which insurance is primary and which is secondary |
| copayments | a fixed dollar amount that must be paid on each visit |
| deductibles | out of pocket before the insurance company will start to pay for covered benefits |
| Medicare Advantage | Combined packages of benefits under Medicare Part A and B |
| Medicaid | Last payment resource |
| Medicaid policies varies | from state to state |
| Medicare | Always pays first |
| Medicare Part A | Hospital coverage |
| Medicare Part B | outpatient & ambulatory services |
| Medicare Part D | Covers drug and medication |
| Medigap | pays most of the charges not covered by Part A and B |
| PCP (primary care physician | Gatekeeper |
| PPO | Insurance plan with flexible and broader network |
| SCHIP(state children health insurance programs) | Medicaid program for children's |
| Third party payers | Insurance companies, medicare, and medicaid |
| Third party liability payers | Worker Compensation, Homeowners, Business Liabilities, Auto Insurance |
| 4 kinds of HMO models | Staff Model, Group Practices, Network, IPA Models |
| CHAMPVA | benefits that covers veterans dependents rated as 100 permantently and totally disabled as a result of the services connected. |
| TRICARE | Military coverage policy |
| TRICARE PRIME | similar to health maintenace organization program (HMO)-military assigned a provider (PCP) |
| TRICARE SELECT | self-managed, (PPO selected) |
| 3 TRICARE PLANS | Standard, Prime, and Extra |
| TRICARE EXTRA | plan developed purposelly for non-active duty military beneficiaries |
| OFFICE CODE | 11 |
| HOSPITAL CODE | 21 |
| MODIFIER 25 | EM CODE TO INDICATE SEPERATE SERVICE ON SAME DAY |
| MODIFIER 59 | SERVICE WAS DISTINCT OR INDEPENDENT FROM OTHER SERVICES ON THE SAME DAY |
| MODIFIER 51 | REFLECT MULTIPLE PROCEDURE PERFORMED AT THE SAME SESSION BY SAME PROVIDER |
| MODIFIER 79 | UNRELATED PROCEDURE BY THE SAME PHYSCIAN DURING POSTOPERATIVE PERIOD |
| MODIFIER GA | INDICATE THAT A PATIENT HAS SIGNED AN ABN (ADVANCE BENEFICIARY NOTIFICATION) |
| MODIFIER GY | USED IN CONJUCTION WITH MODIFIER GA FOR DENTAL PURPOSES |
