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INSURANCE TERMS

Across
the insured person’s share of the bill for a health care after the insurance policy's deductible is exceeded. For example, the payor may be responsible for paying 80%, and the insured pays 20%.
An insurance company or third party that may finance or reimburse the cost of health services.
A process used to determine if a treatment or service will be covered by an insurance company. • These terms are used interchangeably but have the same meaning. • The denial of a prior-authorization request may happen prior to the date of service or afterwards.
Managed Care Organization A group of providers or health care professionals that work together and coordinate care to provide services at affordable rates.
A type of health insurance provided by agents and brokers, but can also be purchased directly from the carrier. Not provided by state or federal governments. These plans vary widely in the types of specific coverage that they provide. o E.g., Blue Cross Blue Shield, Humana, Coventry, United Healthcare, etc.
Discount cards are not true insurance; they advertise discounts or access to discounts on prescriptions. Children’s Mercy does not accept discount cards.
Process of determining payment responsibilities when an individual has coverage through multiple payors (determining which payor has primary payment responsibility). This process is based on insurance industry standards.
A service that offers standardized health insurance plans to individuals, families, and small businesses. Also known as Health Insurance Exchange.
A statement from a health insurance company sent to insured individuals after a claim is processed explaining how that individual’s benefits were applied to that particular claim. It is not a bill, but it includes the date services were rendered, the amount billed, the amount covered, the amount paid by the insurance company, and any balance owed by the insured.
Health insurance plans purchased by an individual (directly from an insurance company or through an employer) that offers coverage for self, spouse and family.
An agreement between a payor and hospital for one instance or course of care for one individual patient. SCAs may need to be negotiated either (1) until a contract is executed, or (2) payment terms are agreed to for coverage exception.
A network plan that covers only a selected number of providers (i.e., hospital or physician groups). Many are designed by payors to reduce costs.
Another word for Policy number
A group of individuals, usually associated with a church or ministry, who share the cost of health care services amongst group members. An individual (or family) can choose to be a cost share group member so that he/she does not have to choose a plan from the marketplace. o Key words that may be visible on _____ plan cards:  Share  Ministries  Christian  This is not insurance
A federal government program that provides a hospital and medical expense insurance plan primarily for Americans aged 65 and older, younger people with disabilities, as well as people with end stage renal disease (ESRD).
Any individual who is covered by the primary insured member’s plan.
Down
Address used by health care provider to send claims to; can usually be found on the back of an insurance card.
A service or procedure that is not covered under the insurance plan
A comprehensive health care reform law passed in 2010 designed to make affordable health insurance available to more people.
A specified dollar amount the insured person pays per provider per visit. the copay is due at the time of the visit.
The current state of an account during the authorization process
Medicare hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care areas.
An integrated pediatric network that coordinates the medical care of pediatric patients enrolled in various managed care organizations (MCOs).  Children’s Mercy _____ is comprised of Children’s Mercy Hospital and its employed physicians, community pediatricians and other health care providers in the Kansas City area.
Process used when patient is without medical coverage; a statement would be sent directly to the patient, as there is no payor involved.
A group of physicians, hospitals, and other health care providers working with the health plan to offer care at negotiated rates.
A set dollar amount that the insured must pay before an insurance company will pay toward a claim.
A healthcare plan available to active or retired military personnel and their families.
A payor denies payment toward a claim. a denial may happen for a variety of reasons, including if the insured has not updated their information, or the claim was sent to the wrong payor first, etc.