Insurance Terms

2. ___________ amount. The difference between the billed amount and the discounted amount for network providers
4. % member pays after deductible
7. - a specific number of visits or dollar amount the plan will pay for (either per year or sometimes lifetime)
8. - The constitution of the plan
14. ___________ billed. Amt non-network prov can charge member above their coinsurance.
15. fixed amount member pays (usually deductible waived
16. - Required by the plan in advance to determine if a procedure will be covered
18. The Federal Governing Body that sets standards for Self-Funded insurance plans
19. - a critical piece of information that tells us who is covered, under which plan, during what time fame
20. - Inpatient ____________ that informs QH of someone admitting into a hospital or other overnight facility

1. ____________ necessity - typically the determining factor in deciding if a procedure is covered
3. a group of providers not in contract with insurance
5. the maximum amount the member will pay in a plan year for covered expenses
6. a group of providers in contract with insurance
9. - recommended by the plan (required by QH) to see if a person can / should have a procedure
10. Amount the member pays before benefits kick in
11. ________ and Customary - The reimbursement rate that quantum will agree to pay for non-network providers
12. - services usually covered 100% by most plans (wellness exams, colonoscopy screenings, screening mammograms, etc)
13. A fixed amount a member pays to have access to insurance
17. not covered by the plan