Chapter 9 Blue Mod

Assignment of benefits

transfer of the patients legal right to collect third-party benefits for medical expenses to the provider of the services

Balance billing

billing the patient for the balance or difference between the physicians charges and the Medicare approved charges

Birthday rule

determination of which policyholder's insurance is the first to pay when a patient is covered by two policies


managed care plan that pays a certain amount to a provider over a specific time for caring for the patients in the plan regardless of what or how many services are performed


person infected with a microorganism but without signs of disease

Claims administrator

an individual who manages the third party reimbursement policies for a medical practice


the agreeed upon amount paid to the provider by a policy holder aka a copayment

coordination of benefits

method of designating the order in which multiple carriers pay benefits to avoid duplication of payment


that part of an insured service the patient must pay

crossover claim

claim that crosses over automatically from one coverage to another for payment


specified amount paid by the policy holder before the carrier begins to pay


spouse, children, and sometimes other individuals designated by the insured who are covered under a health care plan


determination of an insureds right to receive benefits from a third-party payer based on such criteria as payment of premuims and date of start of coverage


person hired to perform given duties in return for financial compensation

explanation of benefits (EOB)

statement that accompanies a payment from an insurance carrier and outlines which dates and services are being paid


an established set of fees charged for specific services and paid by the patient or insurance carrier

fee schedule

list of preestablished fee allowances set for specific services and procedures performed by a provider

group member

policy holder who is a member of a group and covered by the group's insurance carrier

health maintenance organization (HMO)

organization that provides a wide range of services through a contract with a specified group at a predetermined payment

independent practice association (IPA)

several independently practicing physicians contracted with a health maintenance organization to provide services to HMO members


policy that promises to pay some or all of a customers medical bills


an individual who owns a policy that promises to pay some or all of his or her medical bills

managed care

practice of third-party payers to control coses by requiring physicians to adhere to specific rules as a condition of payment


social security established health insurance for the elderly

peer review organization

group of physicians and specialists that conducts a review of a disputed case and makes a final recommendation

physicians hospital organization

a coalition of physicians and a hospital contracting with large employees, insurance carriers, and other benefits groups to provide discounted health services

plan maximum

highest amount paid by a third-party payer for any giver service

preexisting condition

medical problem treated by a physician before an insurance plans effective date

preferred provider organization (PPO)

organization whose purpose is to contract with providers, than lease this network of contracted providers to health care plans

third party administrator

administrator who processes claims for the sponsor of self funded benefit planning


practice of submitting a claim with several seperate procedure codes rather than a single code that represents the services performed

usual, customary, and reasonable (UCR)

the basis of a physicians fee schedule, the usual and customary cost of the same service or procedure in a similar geographic area and under the same or similar circumstances

utilization review

analysis of individual cases by a committee to make sure services and procedures being billed to a third party payer are medically necessary and to ensure compliance with its rules and regulations regarding reimbursement


requests to an insurance company for reimbursement of costs