HEALTH INSURANCE

Types of Health Insurance Plans

A. Indemnity or Fee for Service Plans

B. Managed Care Plans • 1. Health Maintenance Organizations Plans• 2. Preferred Provider Organizations Plans• 3. Point of Service Plans

C. Financial Instruments for Health Care Reimbursement • 1. Health Reimbursement Accounts • 2. Health Savings Accounts and High-Deductible

Plans

Types of Health Insurance Providers

A. Employer-Provided Health Insurance Plans (Self Insured and Purchased)

B. Individually Purchased Health Insurance Plans

C. Federal Employees Health Benefits Program

D. Medicare and Medicaid

• 1. Medicare Parts A and B • A. Part A • B. Part B

• 2. Medicare Part D • 3. Medicare Advantage Plans • 4. Medicare Supplemental Plans • 5. Dual Eligibility – Medicare and Medicaid Recipients • 6. Railroad Retirement Health Insurance • 7. Employer or Union Coverage and Medicare • 8. Medicare open enrollment advantage and medicare

drug programs• 9. Medicaid

E. Childrens Health Insurance Programs (CHIP)

F. Indian Health Services

G. TRICARE

H. Veterans Administration

I. Workers compensation insurance

J. Automobile Insurance

K. Liability and Casualty Insurance

Reimbursement Terminology Overview

A. ICD-9 CM and CPT

B. Resource Based Relative Value Scale

C. Medicare Reimbursement Standards and Arrangements• 1. Medicare Allowed Amount or Medicare Payment

Schedule • 2. Participation and Nonparticipation with

Medicare • 3. Medicare Limiting Charge • 4. Usual and Customary Payment Schedules• 5. Standard Charge Fee Schedules• 6. Contractual Adjustments • 7. Payment Schedules

D. Deductible

E. Copayment

F. Co-Insurance

G. Out of Pocket Maximum

H. Covered Services, Exclusions, and Limitations

I. Primary and Secondary Insurance, and Coordination of Benefits

J. Pre-certification

K. Insurance Verification

L. Primary Physician Referral

M. In-Network and Out of network payment schedules

N. Capitation and Capitated Contracts

Claim Submission Terminology Overview

A. Intermediaries and Carriers

B. Third-Party Administrators

C. Computerized Billing Systems and Electronic Claims

D. Electronic Clearinghouse

E. Electronic Payment Posting

F. Lockbox Payments

Credentialing

Conclusion