Ch. 12 Health Insurance Essentials

4. A system used to determine how much providers should be paid for services provided. It is used by Medicare and many other health insurance companies.
7. A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services.
10. A designated person who receives funds from an insurance policy.
13. A formal request for payment from an insurance company for services provided.

1. The primary care provider, who is in charge of a patient's treatment. Additional treatment, such as referrals to a specialist, must be approved by the gatekeeper.
2. Poor, needy, impoverished.
3. The amount paid or to be paid by the policyholder for coverage under the contract, usually in periodic installments.
5. A payment arrangement for healthcare providers.
6. A written agreement between two parties in which one party (the insurance company) agrees to pay another party (the patient) if certain specified circumstances occur.
8. An organization that processes claims and provides administrative services for another organization. Often used by self-funded plans.
9. Low-income Medicare patients who qualify for Medicaid for their secondary insurance.
11. A document sent by the insurance company to the provider and the patient explaining the allowed
12. An order from a primary care provider for the patient to see a specialist or to get certain medical services.