CHAPTER 17 KEY TERMS

3. A rule that states that the insurance policy of a policyholder whose birthday comes first in the year is the primary payer for all dependents.
6. Term used for the policyholder's spouse and/or children.
7. A fixed percentage of the covered charges paid by the insured person after the deductible has been met.
8. A list of the costs of common services and procedures performed by a physician.
12. Billing program/software that "scrubs" or "cleans" the claims before submission.
15. Information that explains the medical claim in detail, how much was paid for the services provided by the clinic.
17. The amount that is the most the payer will pay any provider for each procedure or service.

1. Authorization or approval for payment from a third-party payer requested in advance of a specific procedure; receipt of confirmation from the insurance company stating that the procedure/service will be covered.
2. A payment structure in which a health maintenance organization prepays an annual set fee per patient to a physician.
4. A health plan that agrees to carry the risk of paying for patient services.
5. "Planned" medical procedure.
6. A fixed dollar amount that must be paid by the insured for charges of providers, or "met", once a year in addition to the premium.
9. Formerly known as Medi/Medi; patient has both Medicare and Medicaid.
10. Also known as an indemnity plan.
11. Payments for medical services.
13. A fixed fee collected at the time of the visit.
14. Plan members with this managed care plan will need to choose a PCP and will need to see their PCP for referrals.
16. Plan members with this managed care plan can choose to receive care from providers outside of the network, but will have to pay more for the visit/services.