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Comprehensive Guide to Medical Insurance Terminology for Clinical Staff

Understand medical insurance terms such as copay, deductible, and EOB with this detailed guide for clinical staff. Explore the intricacies of insurance coverage to provide effective financial health protection for patients.

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Comprehensive Guide to Medical Insurance Terminology for Clinical Staff

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  1. Medical Insurance TerminologyClinical Staff

  2. What is Insurance? Financial health protection for health risk Purchased by an individual or employee Covers an individual and his/her dependents

  3. Who is a Guarantor? The person responsible for payment If a patient is under 18, disabled or an adult with a legal guardian, they must have a guarantor.

  4. Who is a Subscriber? The insurance policyholder.

  5. Who/What is a dependent? Someone that can be covered under an insurance plan (example - spouse, children, nieces, nephews, grandchildren)

  6. What is a Copay? The set amount a patient pays at an office visit.

  7. What is a Deductible? A set amount the patient is responsible for before insurance will pay.

  8. What is Co - insurance? The percentage of payment the patient must pay after the insurance has paid their portion.

  9. Out of Pocket Expense? Amount that isn’t reimbursed by insurance. This includes deductibles, coinsurance, and copayments for covered services plus all costs for services that aren’t covered.

  10. ICD-10 and CPT ICD-10 (International Classification of Disease Vol. 10): Diagnosis code that tells what the patient has. CPT (Current Procedural Terminology): Procedure code that tells what is being done to the patient.

  11. What does EOB stand for? Explanation of Benefits: A statement sent by a health insurance that explains what medical treatments or services were paid for or left for patient responsibility.

  12. Primary / Secondary Insurance When a patient has more than one insurance plan, they will have a primary and a secondary insurance.

  13. In-Network vs. Out of Network • If ADC has a contract with an insurance, we are considered In-Network. • As a general rule, PPO, POS, and HMO plans make use of provider networks. Indemnity plans typically do not.

  14. 3 Categories of Insurance • Indemnity • Managed Care • Government Based

  15. Indemnity Insurance • Group or Individual • Deductible • % based plan (90/10, 80/20) • Any Lab • Any Doctor • Any Hospital

  16. 3 Types of Government Based Plans • Medicare • Medicaid • Tricare (Not accepted as primary insurance at ADC)

  17. Medicare • Medicare Part A (Hospital)•62 years old to qualify•$1,216 deductible (per benefit period) • Medicare Part B (Medical)•65 years old to qualify•$166 deductible•80/20 plan (after patient has paid deductible)•Any Doctor•Any Lab

  18. Medicare • ADC is not contracted with Medicare Advantage/Replacement plans, but will still see established patients only if it is a PPO plan. • The only Medicare Advantage plans ADC is contracted with are Humana Medicare Advantage (PPO, PFFS, Healthselect ERS, and HMO). • Patients with HMO Medicare Advantage/Replacement plans (except Humana) will have to seek care elsewhere.

  19. Medicaid • Some ADC departments will see patients with certain types of Medicaid. • 30 day re-qualification • Pregnant mothers, Terminally Ill, Renal Failure, Disabled

  20. Primary Care Physicians (PCP) • Family Practice • Internal Medicine • Pediatrics • OB/GYN* *ADC OB/GYN providers should not be selected as PCP’s unless the provider has agreed to be the patient’s PCP.

  21. 3 Products of Managed Care Plans • PPO-Preferred Provider Organization • HMO-Health Maintenance Organization • EPO/PoS -Enhanced Provider Organization or Point of Service

  22. PPO - Preferred Provider Organization • Any Physician in the NETWORK • Set co-pay • Assigned- If we are CONTRACTED • Deductible • Stay in Network w/Hospital and Lab • Out of the Network-Insurance pays Reduced Rates

  23. HMO - Health Maintenance Organization • PCP-Primary Care Physician • Referral to see a Specialist • Set co-pay • Assigned- If we are CONTRACTED • Deductible • Out of Network- Insurance pays nothing (0.00)

  24. Enhanced Provider Organization or Point of Service (EPO or PoS) • May require a PCP-Primary Care Physician • May require a referral to see a Specialist • Set co-pay • Assigned- If we are CONTRACTED • Deductible • Out of Network-Some plans will pay Reduced Rates

  25. Marketplace Plans • Ambetter • ADC accepts the Ambetter plan offered through Superior Healthplan on the marketplace. *This is not a Medicaid plan* • Sendero IdealCare • ADC accepts the Sendero IdealCare plan offered through the marketplace. *This is not a Medicaid plan* • Sendero CHIP and Star products are excluded from this contract, as well as Pediatric services

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