CHAPTER 17

1. Also known as an indemnity plan.
4. Plan members with this managed care plan will need to choose a PCP and will need to see their PCP for referrals.
6. A fixed percentage of the covered charges paid by the insured person after the deductible has been met.
7. A payment structure in which a health maintenance organization prepays an annual set fee per patient to a physician.
9. The payment system used by Medicare. It establishes the relative value units for services, replacing the providers’ consensus on usual fees.
11. 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.
14. Also known as explanation of benefits.
17. "Planned" medical procedure.
20. A list of the costs of common services and procedures performed by a physician.
21. A health plan that agrees to carry the risk of paying for patient services.
22. The process of confirming with the insurance company that a patient's insurance plans offers coverage for a specific procedure or service.
23. Billing program/software that "scrubs" or "cleans" the claims before submission.

2. Information that explains the medical claim in detail.
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.
5. Performed by medical peers and used as a cost control measure by managed care organizations.
8. 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.
10. A fixed fee collected at the time of the visit.
12. Formerly known as Medi/Medi; patient has both Medicare and Medicaid.
13. The basic annual cost of healthcare insurance; usually paid monthly by the policyholder/insured.
15. Payments for medical services.
16. Term used for the policyholder's spouse and/or children.
18. The amount that is the most the payer will pay any provider for each procedure or service.
19. 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.