5. A service or supply specified in a contract, for which benefits will be provided pursuant to terms of the contract
6. Benefits accessible to an insured patient to utilize but who are not contracted with the insurance plan.
7. Formerly known as Health Care Financing Administration
10. A restriction placed on coverage by private health plans and Medicare private drug plans.
11. An universal number assigned to a provider that identifies them as the provider of service to the patient.
14. An account available to employees where they have made monetary contributions, usually through payroll deduction, to help offset future healthcare costs.
15. Date of service is provided
19. Health insurance that covers health care after the primary insurance has been made on a claim for medical or hospital care.
20. A patient with no insurance coverage and is responsible for all health care expenses.
22. A group of health care providers who give coordinated care and chronic disease management, and thereby improve the quality of care patients get.
26. Any arrangement for health care in which an organization acts as an intermediary between the person seeking care and the medical care provider
27. Amount of money that is required to be paid by the insured under the insurance contract before any payment is made by the insurer.
28. Descriptive list of terms and numeric codes used for reporting diagnostic and therapeutic procedures and other medical services performed by dietitians and other healthcare providers
30. A type of health care plan used by companies. The company contracts with a third party administrator or self-administers the health care plan.
32. Offered by a private company that contracts with Medicare to provide the person with all Part A and Part B benefits.
34. The amount of money charged by the health care provider or supplier for a certain medical service or supply.
35. Maximum fee that a third party will use to reimburse a provider for a given service.
36. The responsible physician to oversee all aspects of care for a patient.
38. A form or document sent by Medicare to explain healthcare services that was paid by your Medicare benefit.
39. A method of payment for health services and procedures in which a healthcare provider is paid for each service.
41. Provides consumers with greater access to health care insurance, protects the privacy of health care data, and promotes more standardization and efficiency in the healthcare industry.
43. Insurance provided through either a for-profit or not-for-profit company rather than by the federal or state government.
45. Known as a Federal Tax Identification Number
47. A doctor, hospital, health care professional or health care facility.
1. A provider who has entered into a contractual agreement with a third party payer for the provision of services to members on an agreed-upon basis, has satisfied credentialing criteria, and has been accepted as such by the third party payer.
2. Any information that may be used to identify a patient, including but not limited to name, date of birth, address, phone number, or account number.
3. A type of managed care plan that generally covers only the care from providers in this network.
4. A professional provider who has not signed a participating provider agreement with a third party payer and is considered out-of-network.
8. Covers most medically necessary doctors' services, preventive care, durable medical equipment, hospital outpatient services, laboratory tests, x-rays, mental health care, and some home health and ambulance services
9. An optional benefit for prescription drugs available to all people with Medicare for additional charge.
12. A revised classification system by the WHO used to report morbidity and mortality information.
13. A set amount determined by the third party payer that the insured pays to a provider for the treatment or service.
16. A Medicare-approved facility that provides short-term post-hospital extended care services, at a lower level of care than provided in a hospital.
17. A model of care provided by physician practices that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses an patient complaints with coordinated care and a long-term healing relationship.
18. Covers most medically necessary hospital, skilled nursing facility, home health, and hospice care.
21. The largest source of funding for medical and health-related services for people with limited income in the US
23. Described as the "middle ground" between fee for service reimbursement and capitation.
24. Provides health coverage to families with incomes too high to qualify for Medicaid, but can't afford private coverage.
25. A program intended to increase primary care services for Medicaid and Medicare patients in rural communities.
29. A term used to refer to any company that acts as the payer under coverage provided by a health care plan.
31. A statement issued to the insured and the healthcare provider by an insurer to explain the services provided, amounts billed, and payments made by a health plan.
33. The federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with ESRD.
37. A set payment of reimbursement developed by a third party payer to be paid for specific healthcare services and procedures based on CPT/HCPCS codes.
40. Can also be referred to as a participating provider.
42. Patient classification system used by hospitals to bill and be paid by third party payers.
44. Contains vital information about the professional providing the health care service-name, address, registration and licensing/certification. Also contains codes and charges for the service.
46. Insured receive full coverage at minimal cost when they use in-network providers in their health care plan, but can opt to receive services from out-of-network providers at a higher cost.