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Insurance 101

  1. 3. and Customary (CO/ PR 45) : The charge for health care that is consistent with the average rate or charge for identical or similar services in a certain geographical area
  2. 5. Amount: Maximum amount on which payment is based for covered health care services This may be called “eligible expense,” “payment allowance" or "negotiated rate"
  3. 7. Federally administered health insurance program for adults over 65, patients with disabilities and / or End Stage Renal Disease
  4. 8. Software as a Service (QSI Dental Web/ QDW)
  5. 9. / Replacement Claim: A bill frequency type alerting the insurance company that the claim submission is an amendment to a previous submission, with altered / additional / corrected information
  6. 13. A child or other individual for whom a parent, relative, or other person may claim a personal exemption tax deduction and is eligible for health benefits under the subscribers health insurance policy
  7. 15. : Electronic Data Interchange
  8. 16. Explanation of Benefits
  9. 19. Claim Adjustment Reason Codes
  10. 20. : Park Dental's Clearinghouse
  11. 21. The policy owner The person who pays health insurance premiums and / or is eligible for group health insurance benefits
  12. 22. Prepaid Medical Assistance Programs
  13. 23. The health care items or services covered under a health insurance plan Covered benefits and excluded services are defined in the health insurance plan's coverage documents
  14. 24. State administered health insurance program for low income or disabled patients
  15. 25. The patients share of the costs of a covered health care service, calculated as a percentage
  16. 27. Network: Providers or health care facilities that are part of a health plan's network of providers with which it has negotiated a discount
  17. 29. Fixed amount due from the patient at point of service, as supplemental to the insurer's payment for outpatient health care benefits
  18. 33. Coordination of Benefits
  19. 34. Remittance Advice Remark Code; Supplemental to a CARC
  1. 1. of Network: a patient seeking care outside the network of doctors, hospitals or other health care providers that the insurance company has contracted with to provide care
  2. 2. A request for payment that you or your health care provider submits to your health insurer after services are rendered
  3. 4. Electronic Funds Transfer
  4. 6. The amount the patient has to pay out-of-pocket for expenses before the insurance company will cover the remaining costs Deductible obligations exclude copayments
  5. 10. Consolidated Omnibus Budget Reconciliation Act; A Federal law that may allow you to temporarily keep health coverage after your employment ends, you lose coverage as a dependent of the covered employee, or another qualifying event
  6. 11. / DHMO: A dental health maintenance organization (DHMO) is a structured type of dental plan In this type of plan, a set group of dentists provides dental care and the patient must select a primary provider
  7. 12. The process of paying claims submitted or denying them after comparing claims to the benefit or coverage requirements
  8. 14. A type of health insurance arrangement that allows plan participants relative freedom to choose the doctors and hospitals they want to visit
  9. 17. Electronic Claim Submission
  10. 18. Bill: When a provider bills you for the difference between the provider’s charge and the allowed amount
  11. 21. Third Party Liability (ex: workers compensation)
  12. 26. Electronic Remittance Advice
  13. 28. Claim: Formerly called Claim Reversal; A provider initiated electronic void is the cancelation of an entire claim
  14. 30. A request for your health insurer or plan to review a decision or a grievance again
  15. 31. Advantage, Replacement Policy or Medicare Part C: A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits, in addition to RX and dental benefits
  16. 32. Accounts Receivable