Medical Insurance Resource
Medical Insurance Terminology
Point of Service (POS) - A plan that permits patients to receive medical services from non-network providers.
Coinsurance - An agreement between the member and the insurance carrier to share expenses.
Mental Health Expenses - Claims submitted for psychiatric services.
National Correcting Coding Initiative (NCCI) - Developed to control improper coding.
Fee Schedule - List of charges for services provided.
Insurance Reform - Provides continuous insurance coverage for workers and their dependents when they change or lose their jobs.
Participating Physician/ Provider (PAR) - A provider who agrees to provide medical services to a payer's policy holder.
Managed Care Organization (MCO) - Organization offering some type of managed health care plan.
Staff Model (Closed Panel) - Physicians are employed by the HMO.
Medicare Health Insurance Claim Number (HICN) - A unique i.d. number assigned to Medicare beneficiaries.
Reasonable Fee - The lower of either the fee of the physician bill or the usual fee.
Basic Benefits - Benefits usually paid at 100%.
Medicare Summary Notice (MSN) - An explanation of benefits sent to the Medicare beneficiary.
Order of Benefit Determination (OBD) - The thirteen rules that determine the order of payment.
Concurrent Review - Determines whether the length of time of the inpatient stay are justified.
Retrospective Review - Determines after discharge whether the hospitalization and treatment were medically necessary.
Prospective Review - Determines the need of the recommended care.
Carrier - The insurance company.
Non Participating - Providers that do not contract with the insurance company.
Copayment - The fee a patient pays to the provider.
Premium - Monthly payment to the insurance company.
Referral - The transfer of patient care from one physician to another.
Excluded or Non Covered - Services the carrier won't pay for.
Cashflow - Actual money available to the medical practice.
Supplemental Insurance - An insurance that covers benefits that are not covered by the primary plan.
Destination Payer - The payer to which the claim is going to be sent.
Benefits - Payments that the insurance companies make for medical services received.
Date of Service (DOS) - The date of the patient encounter for medical services.
Durable Medical Equipment (DME) - Reusable physical medical supplies.
Pre Existing Conditions - Conditions that existed before the contract.
Carve Outs - Omitted options that are excluded from the medical plan.
Covered Services - Benefits that the carrier will pay for.
Third Party Payer - The insurance company.
Out of Pocket Expenses - What the insured must pay, before benefits begin.
Medigap - Insurance plans designed to cover the expenses that Medicare don't.
Health Maintenance Organization (HMO) - Creates a network of providers to be used by the patient.
Medical Insurance - A company that covers all or some medical expenses.
Subscriber - The insured.
Medicare Part B - Outpatient services.
Coordination of Benefits (COB) - A process that occurs when two or more plans cover the patient.
Guarantor - Refers to the policy holder.
Indemnity Plan - Protection from loss.
Schedule of Benefits - A list of covered expenses that a health plan covers.
Medicare Remittance Notice (MRN) - Used to convey payments to providers who accept assignments for Medicare claims.
Deductible - A certain amount of out of pocket money the patient must meet in order for benefits to begin.
HMO Formulary - A list of medications the HMO is willing to pay for.
Pay To Provider - The person who receives payment.
Adjudication - Process by health plans to examine claims.
Preauthorization - Prior authorization from a payer for services to be provided.
Medicare Part D - The prescription drug component.
Medicare Part A - The basic plan or hospital insurance.
TRICARE - Serves dependents of active duty service members military members. formerly called CHAMPUS
JCAHO (Joint Commission on Accreditation of Healthcare Organization) - Dedicated to maintaining high standards of care in healthcare organizations by directly observing and critiquing hospital and healthcare facilities
CDHP - Consumer Driven Health Plan
Group Model (Open Panel) - HMO contracts with more than one physician.
Capitation - Fixed prepayment to the provider.
Policyholder - The individual/ group that signs the agreement.
Preferred Provider Organization (PPO) - Managed care organization structured as a network of healthcare providers.
Clearinghouse - An independent organization that receives insurance claims from the physician's office.
Medical Insurance Policy - A contact between the individual and the insurance company.
Out of Network Plan - Coverage for treatment from a non participating provider.