Healthcare Insurance Financial Statement

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INSURANCE TERMINOLOGY
1. Admitting Physician
A physician who is formally and legally responsible for admitting a patient to a health care facility
2. Adjuster one who investigates insurance claims or claims for damages and recommends an effective settlement
3. Assignment of benefits
The authorization, y signature of the patient, for payment to be made directly by the patient’s insurance to the provider for services.
4. Balance billing
Sending a financial statement to the patient for the remainder of the amount charged and remaining unpaid after the third-party payer has submitted their financial contribution.
5. Capitation
Providers are paid a set fee per patient on their patient listing each month, whether the patient is seen one or more times or not at all.
6. Carrier/Rider
Refer to insurance companies that reimburse for health care services
7. Claim
A statement from a patient or health care provider presented to an insurance company or HMO for payment for services performed.
8. Coding
Is the conversation of written descriptions of diseases, injuries, procedures, and services into numeric or alphanumeric characters.
9. Coordination of benefits (COB)

When both spouses have health care insurance,the policy provision that limits benefits to 100% of the cost; also known as dual coverage.
10. Co-insurance
A percentage that a patient is responsible for paying for each service after the deductible has been met.
11. Co-payment
Specified amount the insured must pay toward the charge for professional services rendered at the time of services.
12. Current procedural terminology (CPT)
Consists of six sections. Level II National codes are used to report supplies and services for which there are no current CPT codes.
13. Deductible
A predetermined amount the insured must pay each year before the insurance company will pay for an accident or illness.
14. Effective date
The date when the insurance policy goes into effect.
15. Electronic claim
A digital representation of a medical bill generated by a provider or by the provider's billing agent for submission using telecommunications to a health insurance payer.
16. Elimination
To remove, get rid of, exclude; also to pass urine from the bladder or stool from the bowel.
17. Exclusion
Items or services that Medicare does not cover, such as most prescription drugs, long-term care, and custodial care in a nursing or private home
18. Explanation of benefits
A printed description of the benefits provided by the insurer to the beneficiary.
19. Fee schedule
A list of predetermined payment amounts for professional services provided to patient.
20. Gate keeper Term given to primary care providers because they are responsible for coordinating the patient’s care to specialists, hospital admissions, and so on.
21. Group insurance
Insurance offered to all employees by an employer.
22. Health Maintenance Organization (HMO)
Group insurance that entitles members to service provided by participating hospitals, clinics, and providers.
23. HCFA 1500 name for the professional uniform claim form
24. Indemnity plan
A commercial plan in which the company(insurance) or group reimburses providers or beneficiaries for services; allows subscribers more flexibility in obtaining services.
25. Independent Practice Association (IPA)

26. International Classification of Diseases (ICD-9)

Is required on all claims to report morbidity and mortality of the patient. Codes describe the disease or condition presented by the patient. Establishes the medical necessity for the services and procedures provided to the patient.
27. Major medical insurance designed to cover medical expenses due to severe or prolonged illness by paying all or most of the bills above a set amount
28. Medicaid
A joint funding program by federal and state governments for the medical care of low-income patients on public assistance.
29. Medigap (medifill)
Private insurance to supplement Medicare
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