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  1. Allowed Charge
    (Allowable Amount)
    The maximum amount of money that many third-party payors allow for a specific procedure or service.
  2. Authorization
    A term used in managed care for an approved referal
  3. Beneficiary
    individual entitled to receive benefits from an insurance policy or program or governmental entitlement program offering health care benefits also called a participant, subscriber, dependant, enrollee, or member.
  4. Benefits
    The amount payable by an insurance company for a monetary loss to an individual insured by that company under each coverage.
  5. Birthday Rule
    Under law the ruling stating that when and individual is covered under 2 insurance policies, insurance plan of the policy holder who's birthday comes first in the calendar year (month and day, not year) becomes the primary insurance. This rule applies when there is a question as to who's insurance should be determined as primary, such as for a dependant child, and used when the individual is the owner of one of the 2 policies, which would make that the primary policy.
  6. Capitation
    Payment method used be many managed care organizations were in a fixed amount of money is reimbursed to the provider for patients enrolled during a specific period of time, no matter what services were received or how many visits were made.
  7. Carriers
    As a related to insurance, companies that assume the risk of an insurance policy.
    A government sponsored program where in authorized dependants of military personnel receive medical care. This program was originally called CHAMPUS
  9. Civilian Health an Mdical Pogram of the Vrteran Aministration (CHAMPVA)
    A health benefit program run by the department of verterans affairs ( VA) that helps eligible beneficiaries pay the cost of specific healthcare services and supplies.
  10. Co-insurance
    A policy provision frequently found in medical insurance whereby the policyholder and the insurance company share the cost of covered losses in a specified ration (e.g. 80/20 means 80% is covered by the insurer and 20% by the insured).
  11. Commercial Insurance
    Plans that reimburse the insured for expenses resulting from illness or injury according to a specific fee schedule as outlined in the insurance policy and on a Fee-For Service basis. Sometimes called private insurance.
  12. Copayment
    A sum of money that is paid at the time of medical service; a form of medical insurance.
  13. Deductables
    Specific amounts of money a patient must pay out of pocket before the insurance carrier begins paying. Ususally this amount ranges from $100 to $500. This deductible amount is met on a yearly or per-incident basis.
  14. Dependants
    The spouse, children, and sometimes domestic partner or other individuals designed by the insured who are covered under a healthcare plan.
  15. Disability Income Insurance
    Insurance that provides periodic payments to replace income when an insured person in unable to work as a result of illness, injury, or disease.
  16. Effective Date
    The date on which an insurance policy or plan takes effect so that benefits are payable.
  17. Eligibility
    A term which describes whether a patient's insurance coverage is in effect, and eligible for payment of insurance benefits.
  18. Exclusions
    Limitations on an insurance contract for which benefits are not payable.
  19. Explanation of Benefits (EOB)
    A letter or statement from the insurance carrier describing what was paid, denied, or reduced in payment. It also contains information about amounts applied to the deductible, the patient's co-insurance and the allowed amounts.
  20. Explanation of Medicare Benefits (EOMB)
    The EOMB is the name for an explanation of benefits from Medicare (see EOB for more explanation of this definition).
  21. Fee for Service
    An established schedule of fees set for services performed by providers and paid by patient.
  22. Fiscal Intermediary
    An Organization that contracts with the government to handle and mediate insurance claims from medical facilities, home health agencies, or providers of medical services or supplies.
  23. Government plans
    Entitlement programs or healthcare plans that are sponsored and/or subsidized by the state or federal goverenment, such as Medicaid and Medicare.
  24. Group Policy
    Insurance written under a policy that covers a number of people under a single master contract issued to their employer under a single master contract issued to their employer or to an association with which they are affiliated.
  25. Guarantor
    The person who is responsible for paying a medical bill.
  26. Health Insurance
    Protection in return for periodic premium payments that provides reimbursement of expenses resulting from illness or injury. includes the following forms of insurance: accident, disability income, medical expense, and accidental death and dismemberment. Also known as accident and health insurance or disability insurance.
  27. Health Insurance Portability and Accountability Act
    The Kassebaum-Kennedy Act, designed to improve portability and continuity of health insurance coverage; to combat waste, fraud, and abuse in health insurance and healthcare delivery; to promote the use of medical savings accounts; to improve access to long-term care services and coverage; to simplify the administration of health insurance; and to serve other purposes.
  28. Health Maintenance Organization (HMO)
    An organization that provides a wide range of comperhensive healthcare services for a specified group at a fixed periodic payment. HMOs can be sponsored by the government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies, and hospital-medical purposes.
  29. Indemenity Plans
    Traditional health insurance plans that pay for all or a share of the cost of covered services, regardless of which physician, hospital, or other liscensed healthcare provider is used. Policyholders of indemnity plans and their dependants choose when and where to get healthcare services.
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