Chapter 12- Health Insurance Essentials

2. An online service provided by various insurance companies that allows providers to look up a patient's insurance benefits, eligibility, claims status, and explanation of benefits.
3. Poor, needy, impoverished.
7. 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.
13. A list of fixed fees for services.
14. A formal request for payment from an insurance company for services provided.
16. A payment arrangement for healthcare providers.
17. The length of time a patient waits for disability insurance to pay after the date of injury.
18. A health problem that was present before new health insurance coverage started.
19. 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.
20. An organization that processes claims and provides administrative services for another organization. Often used by self-funded plans.

1. Low-income Medicare patients who qualify for Medicaid for their secondary insurance.
4. An online marketplace where people can compare and buy individual health insurance plans. State health insurance exchanges were established as part of the Affordable Care Act.
5. A decision-making process used by managed care organizations to manage healthcare costs. It involves case-by-case assessments of the appropriateness of care.
6. A document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, and the patient's financial responsibilities.
8. A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services.
9. A designated person who receives funds from an insurance policy.
10. An approved list of physicians, hospitals, and other providers.
11. 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.
12. An order from a primary care provider for the patient to see a specialist or to get certain medical services.
15. The amount paid or to be paid by the policyholder for coverage under the contract, usually in periodic installments.