Chapter16

To settle judicially as in a determination of payment in an insurance claim

A person who acts for carrier or the insured in the settlement of claims:also knw as claim representative

An agreement by wich a patient assigns to another party the right to receive payment from a 3 party for the service the patient has receive

A sum of money provided in as insurance policy and payable for certain losses or 4 services received

A method of payment 4 health services by which a health group is prepaid a fix per capital amount for each patient served

An organization that offers financial protection against losses in exchange 4 a premium;ynonyms,insurer,underwriter

A request for payment under an insurance contract or bond

Centralized location where claims are received,edited,and distributed electronically to insurance companies

A cost-sharing requirement under a health insurance policy that stipulates the insured assume a percentage of the cost of covered services

In an insurance contract, broader coverage of disease or accidents and higher indemnity payments

Provisions and procedures used by insurance to avoid duplicated payment for losses insured under more than one insurance policy

A type of cost sharing flat fee whereby the insured pays a specified amount per unit of service and the insurer pays the rest of the cost

An amount the insured must pay in a calendar or fiscal year before policy benefits begin

Under an insurance contract, the spouse and children of the insured

Any limitation of physical,mental,or social activity of a person as compared with other people of similar age,sex. May be partial total,perm

Period of time after the onset of a disability for which no benefits will be paid

A waiting period after the beginning date of a policy during which benefits are not payable

Specific hazards,perils,or conditions listed in an insurance policy for which the policy will not pay

A recap sheet that accompanies an insurance check showing the breakdown and explanation of payments on a claim

Coverage supplemental to either a basic hospital plan or basic hospital surgical media plan, sometimes x.ray are considered ex benfits

A method of charging whereby a physician or other practitioner bills for each encounter or service rendered

A contractor that process and pays provider claims on behalf of state or federal agencies or insurance companies;also called fiscal agent

A specified time interval after a premium payment is due policy holder make a payment,protection of the policy continues

Compensation provided under a policy for hospitals charges incurred by an insured person because of an illness or injury

Benefits paid in a predetermined amount in the event of a covered loss

A person who is a bed patient in a hospital

A representative of an insurance company licensed by the state who solicits negotiates or effect contracts of insurance

A singed statement of facts request by an insurance company on the basis of winch it decides whether or not to issue policy

Individual or organization protected in case of loss under the terms of an insurance policy

Provision of an insurance policy that list exceptions or reductions to specific coverage

A policy especially designed to offset heavy medical expenses resulting from catastrophic or prolonged illness or injury

A provision whereby the insurance carrier assumes o liability,frequently leaving the patient with out-of pocket expenses when a patient is c

Patient ambulatory care at hospital or other facility without being admitted as bed patient

An illness or injury that permanently prevents a person from performing one or more functions of a regular job

Doctor who agrees to accept an insurance plans preestablished feeor reasonable charge as the maximum amount collected for services rendered

Illness or injury that prevents an insurance person from performing all the functions of a regular job

To determine where treatment is covered under a patients health insurance policy

Finding out the maximum dollar amount that will be paid for surgery,consulting services,postoperative care.

An injury that occurred,diseased .or physical condition that existed before the issue of a health insurance policy

Payment made periodically to keep an insurance policy in force

The evaluation of a provider request for a specific service to determine the medical necessity and appropriateness of the care request 4 a p

A person or institution that gives medical care

Form that must b singed by the patient before information may b given to an insurance company.

In insurance one who signs up for a GROUP insurance plan. Enrolle,insured,or policyholder

An insurance carrier other than the physician or patient who intervenes to pay hospital expenses. Know as 3thrd party carrier

The period of time in wich a notice of claim or proof of loss must b filed

A usual fee is one that an individual physician normally charges for a given professional services to a private patient

The time that must elapse before a benefit is paid also know as excepted period

An attachment to an insurance policy that excludes certain illnesses or disabilities that would otherwise b covered