Notes

Insurance Terminologist
*Deductible- An amount you are required to pay before a plan begins to share the cost of prescriptions.
*Initial coverage limit- the stage wherein you and the plan "cost-share" on the cost of the prescription. This stage comes from when the member has completed the deductible stage
*Coverage gap- a Medicare prescription drug coverage stage following the Initial Coverage stage. This is also known as "donut hole"
*Catastrophic Coverage- a phase of coverage designed to protect you from having to pay very high out-of-pocket costs for prescription drugs.
*Over-the-counter- medicines that do not require a prescription.
*Medicare- federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease.
*Formulary- a list of drugs that are covered by the plan
*Premium- a monthly fee for the members to have healthcare insurance coverage

COMMON MEDICAL TERMS
*Group Health Insurance- offered by an employer or other organization that covers the individual in that group and their dependents under a single policy
*In-Network Provider- a healthcare professional, hospital, or pharmacy that is part o f a health plan's network of preferred providers. - affiliated doctors
*Out-of-Network Provider- professional, hospital or pharmacy that is not part of health plan's network of providers.
*Benefit- the amount of payable by the insurance company to a plan member for medical costs.
*Benefit level- a maximum amount that a health insurance company has agreed t pay for a covered benefit.
*Benefit Period- a span of time which a member must incur expenses to satisfy deductibles and coinsurance. For each benefit a new deductible and coinsurance maximum applies
*Calendar Year Plan Year-= Calendar Year- January 1st to December 31st
=Plan Year- Begins first day of the policy and continue 12 months
*Claim- a request by a plan customer, or a plan customer's health care provider, for the insurance company to pay for medical services.
*Deductible- the amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.
*Coinsurance- amount you pay to share te cost of covered services after your deductible has been paid.
*Copayment- one of the ways you share in your medical costs. You pay a flat fee for certain medical expenses, example $10 for every visit to the doctor), while our insurance company pays the rest
*Dependent- any individual, either spouse or child, that is covered by the primary insured customer's plan
*Plan- a benefit your employer, union or other group sponsor provides to you to pay for your health care services
*Pre-authorization- a decision by your health insurer or plan that a health care services, treatment plan, prescription drug or durable medical equipment is medically necessary. called PRIOR AUTHORIZATION, prior approval or precertification
*Allowed amount- maximum amount on which payment is based for covered health care services. This may be called eligible expense payment, allowance or negotiated rate. If your provider charges ore than the allowed amount, you may have to pay the difference.
*Out-of-Pocket- the most you pay during a policy period( usually a year) before your health insurance or plan begins t pay 100% of the allowed amount
*Explanation of Benefits- written explanation on how a medical claim was paid. It contains detailed information about what the company paid and what position of the costs you are responsible for
*Provider- any person or institution that provides medical care
*Appeal- a request for your health insurer or plan to review a decision or grievance again.
*Institutional Provider- a type of the provider medical services performed by the hospital or facility
*Professional Provider- provide medical services perform by the individual or professional doctors
*Primary Care Physician
*Specialist- if beyond the scope of PCP or if they can't treat the member they will recommend it to the specialist

COMMON MEDICAL SERVICES
*Impatient stay- patients requires to stay in a hospital for more than 24 hours
*Outpatient care- a patient who is not hospitalized and discharged after less than 24 hours
*Skilled Nursing Facility- a residential facility for person with chronic illness or disability, particularly older people. "Nursing home or long term care facility"
*Hospice- supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life rather than cure
*Chemotherapy - treatment of cancer with drugs that can destroy cancer cells.
*Intravenous therapy ( IV THERAPHY)- administration of liquid substance directly to the vein. fastest way to deliver fluids and medications throughout of the body
*Durable medical equipment (DME)- purchased or rented items such as hospital beds, iron lungs, oxygen equipment, wheelchairs, hearing aids, those equipment prescribed to be used at home
*Prosthetic/prosthesis- artificial devices used to replace a missing body part, such as limb, tooth, eye, or heart valve.
*Infertility- diminished ability men and women or the inability to reproduce
*Sterilization- unable to reproduce sexually
TYPES OF STERILIZATION
1.Vasectomy (MEN) - surgical removal of all or part of the vas deferens
2.Tubal ligation(WOMEN) - prevent sperm from reaching the fallopian tube to fertilize an egg
*Preventive Care- prevention and/or reduction of illness by preventing such services as regular physical examination
TYPES OF PREVENTIVE CARE
1.Well Baby- regularly scheduled examinations during first two years of life
2.Well Child- check ups to keep a child healthy
3.Immunization- immunity against infectious disease
4.Routine Papsmear- collects cells from the cervix to detect cervical cancer
5.Routine mammogram- imaging the breast
6.Prostate Specific Antigen -
7.Routine Exam
8.Routine Vision
9.Flu Shot

*Diagnostic Procedures- a symptom or a distinguishing feature serving as supporting evidence in a diagnosis
Examples of Diagnostic Procedures
1.Magnetic Resonance Imaging
2.Magnetic Resonance Angiography
3.Computed Axial Tomography
4.Bone Density
5.Nuclear Cardiology
6.Sleep Study
7.Ultra Sound
8.Mammography

*Surgical Procedures- the removal or replacement of diseased organ or tissue. Branch of medicine that deals with the diagnosis and treatment of injury, deformity and disease by manual and instrumental means
1. Biopsy
2.Colonoscopy

*Rehabilitation Therapy- wide range of injuries or conditions. Orthopedic and musculoskeletal injuries, neurological injuries, and multi-trauma injures
1. Occupational Therapy
2. Speech Therapy

*Physical Medicine- physiatry or rehabilitation medicine, aims to enhance and restore functional ability and quality of life to those with a physical impairments or disabilities affecting the brain, spinal cod
1. Physical Therapy
2. Chiropractic


MEDICAL CODES
1.Procedure codes- identify what services were provided and why
*CPT CODES- five digit main number to describe PARTICULAR SERVICES
Evaluation and MANAGEMENT 99200-99499
Anesthesia 00100-01999
Surgery 10000-69999
Radiology, Nuclear Medicine and Diagnostic Ultrasound 70000-79999
Pathology and laboratory 80000-89999
Medicine
*HCPCS- 5 character alphanumeric code
Transportation
Chiropractic services
Medical and surgical services
Miscellaneous and experimental
*Revenue code
*Modifier codes- two-character code, billed with a procedure code (CPT or HCPCS)
*Diagnosis Codes
1. v codes-
2. e codes-