| A | B |
|---|
| Policyholder | A person or entily who buys an insurance plan; the insured |
| Premiums | The periodic amount o money the insured pays to a health plan for insurance coverage |
| Payer | Private or government organization that insures or pays for healthcare on behalf of beneficiaries |
| Indemnity plan | Also known as a fee-for-service plan; a health plan tha reimburses the policyholder for a percentage of covered medical expenses |
| Managed care | A type of insurance in which the carrier is responsible for both the financing and delivery or healthcare |
| Preferred Provider Organization (PPO) | Managed care network of healthcare providers who agree to performe services for plan members at discounted fees |
| Health Maintenance organization (HMO) | A managed healthcare system in which providers agree to offer healthcare to the organization's members for fixed payments |
| Copayment | A Fixed fee paid by the patient at the time of an office visit |
| Capitation | Payment to a provider that covers each plan member's healthcare services for a certain period of time |
| Point-of-service-(POS) plan | A plan, combining features of an HMO and PPO, in which members may choose from providers in a primary or secondary network |
| Deductible | Amount due before benefits begin |
| Coinsurance | Percentage of charges that an insured person must pay for healthcare services after payment of the deductible amount |
| High-duductible health plan with savings option (HDHP/SO) | A type of managed care insurance in which a high-deductible plan is combined with a pretax savings account to cover out-of-pocket medical expenses |
| Medical necessity | Treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appreciate and is provided in accordance with generally accepted standards of medical practice |
| Clean claims | Claims with all the correct information necessary for payer processing |
| X 12 837 Health Care Claim or Equivalent Encounter Information (837P) | HIPAA standard format for electronic trnsmission of a professional claim from a provider to a health plan |
| CMS-1500 | The mandated paper insurance claim form |
| Navigator buttons | Buttons that simplify the task of moving from one entry to another |
