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BV Terminology

Across
Physician purchases EYLEA and submits claims for reimbursement to insurance company.
federally funded insurance, for the aged and disabled who meet certain criteria
The maximum dollar amount a medical plan will pay toward the cost of medical care incurred by an individual or family in a specified policy year.
Codes used to tell what the MD did to the patient
Total dollar amount that a health plan will pay for covered healthcare services during a specified period, such as one year.
state-funded insurance for individuals and family with low income and limited resources
Provides eligible veterans a standard medical plan with preventative and primary care,
Employer-established savings account that allows participants to be reimbursed for certain medical expenses
Consolidated Budget Reconciliation Act of 1985
Is a unique ten-digit identification number required by HIPAA for all health care providers
The supplementary or “physician insurance” portion of Medicare.
The determination of the nature of a case of a disease or the distinguishing of one disease from another
A plan where the employer contracts with another organization to assume financial responsibility for the enrollees’ medical claims
Facility purchases EYLEA and submits claims for reimbursement to insurance company.
Down
A Pharmacy benefit manager (PBM) is a company that administers, or handles, the drug benefit program for your employer or health plan
Helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities
A predetermined fee that a plan member pays for healthcare services
A medical provider or healthcare facility that is not part of a health plan’s list of preferred healthcare providers
Summary of Benefits
This is the process of researching and identifying policy-specific coverage
The date that coverage began for a person enrolled in a health plan.
Prior authorization is a “prior approval” for a specific service or treatment
Amount an individual must pay for medical expenses before insurance covers a portion of the costs.
Policy holders are assigned a policy number to identify their particular plan. It is always necessary when verifying benefits.
Refers to a provider of medical services that agrees to a health plan network’s terms and conditions.
When a primary care doctor transfers care of a patient to a specialist
The total dollar amount that a health plan will require an insured individual to pay for healthcare services during a fixed time period