CHAPTER 17

7. 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.
9. The amount that is the most the payer will pay any provider for each procedure or service.
10. Also known as an indemnity plan.
12. A list of the costs of common services and procedures performed by a physician.
14. "Planned" medical procedure.
15. Formerly known as Medi/Medi; patient has both Medicare and Medicaid.
16. A payment structure in which a health maintenance organization prepays an annual set fee per patient to a physician.
17. 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.
18. 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.

1. Plan members with this managed care plan will need to choose a PCP and will need to see their PCP for referrals.
2. Payments for medical services.
3. A fixed fee collected at the time of the visit.
4. Information that explains the medical claim in detail, how much was paid for the services provided by the clinic.
5. Billing program/software that "scrubs" or "cleans" the claims before submission.
6. A fixed percentage of the covered charges paid by the insured person after the deductible has been met.
8. 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.
11. Term used for the policyholder's spouse and/or children.
13. A health plan that agrees to carry the risk of paying for patient services.