HAP 410 FINAL EXAM STUDY GUIDE
QUESTIONS AND CORRECTS
ANSWERS
Know /Define terms in "Who's Who" in Health Insurance -
sw sw sw sw sw sw sw sw sw
swProvider: is the medical professional who provides the healthcare services to the pa
sw sw sw sw sw sw sw sw sw sw sw sw
tient. In the medical office, this is usually the doctor, nurse practitioner, and physicia
sw sw sw sw sw sw sw sw sw sw sw sw sw
n assistant.
sw sw
Policy Holder: whose name is covered by the insurance company. Ultimately respon
sw sw sw sw sw sw sw sw sw sw sw
sible for payment of the bills. Makes it possible for Dependents (spouse, children, si
sw sw sw sw sw sw sw sw sw sw sw sw sw
gnificant other) of the insured to be covered.
sw sw sw sw sw sw sw
Carrier - is the one that writes and administers the health insurance policy
sw sw sw sw sw sw sw sw sw sw sw sw
Self Insured - sw sw
(A company, usually large) that creates a fund for collection of premiums/
sw sw sw sw sw sw sw sw sw sw sw sw
payments of claims for its employees. The Third Party Administrator is the outside c
sw sw sw sw sw sw sw sw sw sw sw sw sw
ompany that administers the plan, processes the claims, etc. for their employees. Th
sw sw sw sw sw sw sw sw sw sw sw sw
e company assumes the risk of providing health care to their employees.
sw sw sw sw sw sw sw sw sw sw sw
Beneficiary - sw
the person eligible to receive benefits under the health insurance policy.
sw sw sw sw sw sw sw sw sw sw sw
Define Medicare and who is eligible -
sw sw sw sw sw sw
This started in 1965 under President Lyndon Johnson. A federal health insurance e
sw sw sw sw sw sw sw sw sw sw sw sw sw
ntitlement program compliments the Social Security, passed in 1935. The beneficiary
sw sw sw sw sw sw sw sw sw sw
eligibility include individuals 65+, younger individuals with disabilities, and individuals
sw sw sw sw sw sw sw sw sw sw
with end stage renal disease.
sw sw sw sw sw
Four Parts of Medicare -
sw sw sw sw
Medicare, Part A...hospital services, including inpatient hospitalization, Skilled nursin
sw sw sw sw sw sw sw sw sw
g, Home care, hospice care. Patients have a 90 day hospital stay benefit in a given
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw s
wbenefit period (usually one year), plus a 60 day lifetime reserve. Patient must enroll
sw sw sw sw sw sw sw sw sw sw sw sw sw s
wat the time just before or after 65th birthday. Premiums covered under Social Securi
sw sw sw sw sw sw sw sw sw sw sw sw sw
ty.
Medicare Part B....Physician/ sw sw
nurse practitioner services services, outpatient hospital services, hospital and ambula
sw sw sw sw sw sw sw sw sw
,tory surgery, physical and speech therapy, chemotherapy. Patient must be enrolled i
sw sw sw sw sw sw sw sw sw sw sw
n Part A, and then pays monthly premium out of pocket.
sw sw sw sw sw sw sw sw sw sw
Medicare Part C...... Started in 1997, also called Medicare Advantage or Medicare M
sw sw sw sw sw sw sw sw sw sw sw sw
anaged Care. Broader in- sw sw sw
network coverage (more restrictive), lower out of pocket costs vs. Medicare Part B.
sw sw sw sw sw sw sw sw sw sw sw sw sw
Plans to phase this down/maybe out.
sw sw sw sw sw
Medicare Part D......started in 2006. Voluntary drug benefit program. Patient must en
sw sw sw sw sw sw sw sw sw sw sw
roll in a private insurance plan approved by Medicare for Part D. Coverage. A restric
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
ted formulary is provided based on the diagnosis and treatment of a medical conditi
sw sw sw sw sw sw sw sw sw sw sw sw sw
on.
Key players of Medicare and how its works - -
sw sw sw sw sw sw sw sw sw
Federal Government: Congress mandates and Medicare rules and regulations
sw sw sw sw sw sw sw sw
-
Medicare Administrative Agencies: Operational responsibility. Under the Dept. of Hea
sw sw sw sw sw sw sw sw sw
lth and Human Services is CMS (Center for Medicare Services)
sw sw sw sw sw sw sw sw sw
-Non-
Governmental Medicare Agencies...Private companies called intermediaries, who con
sw sw sw sw sw sw sw
tract with CMS to process claims. Also called MACs (Medicare Administrative Contra
sw sw sw sw sw sw sw sw sw sw sw
ctor). Very often a private insurance company as Blue Cross or Aetna may serve as
sw sw sw sw sw sw sw sw sw sw sw sw sw sw s
wintermediaries for Medicare in different sections of the country, since they have the i
sw sw sw sw sw sw sw sw sw sw sw sw sw
nfrastructure in place. sw sw
-Hospitals provide services under Medicare Part A.
sw sw sw sw sw sw
sw
-
Physicians provide services under Medicare Part B...Note that a physician can be a
sw sw sw sw sw sw sw sw sw sw sw sw sw
participating or non- sw sw
participating provider. To be participating, a physician must submit an application for
sw sw sw sw sw sw sw sw sw sw sw
m to Medicare to provide services to beneficiaries. An NPI (National Provider Identifi
sw sw sw sw sw sw sw sw sw sw sw sw
er) number is assigned for billing.
sw sw sw sw sw sw
-
Participating provider sees Medicare beneficiaries and "accepts assignment" which m
sw sw sw sw sw sw sw sw sw
eans that they accept Medicare's fee schedule. Medicare pays 80% of allowable rei
sw sw sw sw sw sw sw sw sw sw sw sw
mbursement, with remaining 20% collected from the patient.
sw sw sw sw sw sw sw sw
-Non-
participating...doctor does not accept assignment. Fee schedule is 95% of fee sched sw sw sw sw sw sw sw sw sw sw sw
ule for participating provider. Payment of the claim sent to patient, not to doctor. Be
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
neficial for doctor to be participating.
sw sw sw sw sw
Define Medicaid, who it covers, basic elements -
sw sw sw sw sw sw sw
provides benefits to low income groups with no or limited health insurance. Federal
sw sw sw sw sw sw sw sw sw sw sw sw sw s
,government provides general guidelines and funding, but Medicaid programs are ad
w sw sw sw sw sw sw sw sw sw sw
ministered by each state. Fee schedule is usually less than Medicare, maybe 75-
sw sw sw sw sw sw sw sw sw sw sw sw
80% of Medicare fee schedule. Usually $3.00 co-
sw sw sw sw sw sw sw
pay. The indigent population, along with low reimbursement makes it unpopular with
sw sw sw sw sw sw sw sw sw sw sw sw
most doctors. Covers basic preventive services, "bare bones coverage"
sw sw sw sw sw sw sw sw
Define Tricare, who it covers, basic elements - -
sw sw sw sw sw sw sw sw
Worldwide health services with military facilities that provides services for the military
sw sw sw sw sw sw sw sw sw sw sw
and their families. Which includes.....active duty.....retired service members,.......activ
sw sw sw sw sw sw sw sw
e/non active/retired National Guard.
sw sw sw
-Tricare provides network (military medical personnel and facilities) and non-
sw sw sw sw sw sw sw sw sw
network .benefits. Only specialized/
sw sw sw
medically necessary services usually provided out of network
sw sw sw sw sw sw sw sw
-
The VA (Veterans Administration) provides acute care, ambulatory, and rehabilitation
sw sw sw sw sw sw sw sw sw s
wservices to veterans. sw sw
-There are also military hospitals (Walter Reed. Bethesda Naval) for active military
sw sw sw sw sw sw sw sw sw sw sw
Types of plans - Fee for Service/Indemnity, PPO, HMO (capitation), HDHP
sw sw sw sw sw sw sw sw sw sw
Fee for Service/Indemnity -
sw sw sw
Health insurance of the 1960's, now rare because it is so expensive. First dollar co
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
verage, usually 80% covered, 20% out of pocket co-
sw sw sw sw sw sw sw sw
insurance. Flexibility to choose any doctor or hospital.
sw sw sw sw sw sw sw
Preferred Provider Organizations (PPO) -
sw sw sw sw
(Has some model features of Fee for Service) Insurance companies contract with n
sw sw sw sw sw sw sw sw sw sw sw sw sw
etworks of providers and hospitals, from which the patient can select. Doctor accept
sw sw sw sw sw sw sw sw sw sw sw sw
s/
insurance and patient pays a lower rate, in exchange for joining the network. Going
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
"out of network" is much more costly for the patient. Primary care gatekeeper is usu
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
ally not required.
sw sw
Health Maintenance Organization (HMO) -
sw sw sw sw
focuses on preventive care. Primary care physician is the gatekeeper in the networ
sw sw sw sw sw sw sw sw sw sw sw sw sw
k established by the insurance carrier, which means that referrals are required to se
sw sw sw sw sw sw sw sw sw sw sw sw sw
e a specialist, and pre-
sw sw sw sw
authorizations to be admitted to a hospital. Going out of network usually prohibited.
sw sw sw sw sw sw sw sw sw sw sw sw sw
Per some plans, the primary care doctor paid on a captitated basis, which means a
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
set fee, is received per member per month, to manage the care of the patient with
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
a focus on prevention. Kaiser Permanente is a nationally known one.
sw sw sw sw sw sw sw sw sw sw
, (HDHP) High Deductible Health Plans/Consumer Directed Plans: -
sw sw sw sw sw sw sw
Due to high healthcare costs, many companies are shifting costs to their employees
sw sw sw sw sw sw sw sw sw sw sw sw sw
through higher deductibles. To go with the "stick" of higher deductibles, the 'carrot"
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
is allowing individuals and companies to put "pre-
sw sw sw sw sw sw sw
tax" dollars in accounts to help pay for the high front end deductibles.
sw sw sw sw sw sw sw sw sw sw sw sw
Laws have been passed by Congress, where Health Savings Accounts (HAS), Healt
sw sw sw sw sw sw sw sw sw sw sw
h Reimbursement Accounts (HRA) and Flexible Spending Accounts (FSA) have bee
sw sw sw sw sw sw sw sw sw sw
n created.
sw
In 2011, pre-
sw sw
tax medical savings accounts under high deductible account allowances are now $1,
sw sw sw sw sw sw sw sw sw sw sw
200 per individual, and $2,400 for a family. Insurance benefits start after the deducti
sw sw sw sw sw sw sw sw sw sw sw sw sw
ble is met. sw sw
Premium - sw
Paid monthly in return for coverage under the policy. Price based on contracted be
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
nefits in the health policy. Most employers pay a portion of the premium, with the e
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
mployee paying a portion based on a designated payroll deduction.
sw sw sw sw sw sw sw sw sw
Co-Payment - sw
Required payment to the provider or institution at the time of service, per the policy
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
. Very common for patient to pay a $10-$25 in a doctor's office for this.
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
Deductible - sw
First dollar out of pocket payment required by some plans before the insurance co
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
mpany pays. The patient, not insurance company at risk for payment of services at t
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
he beginning of the plan year.
sw sw sw sw sw
Insurance payment - sw sw
Portion of health services paid by the insurance carrier. Amount paid is in the insur
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
ance policy. sw
Co-Insurance - Service balance that remains after the deductible and co-
sw sw sw sw sw sw sw sw sw sw
pay has been paid, which is the responsibility of the insured.
sw sw sw sw sw sw sw sw sw sw
Exclusions - sw
services not covered in the policy (common are laser eye surgery, cosmetic surgery
sw sw sw sw sw sw sw sw sw sw sw sw sw
, fertility treatments.)
sw sw
Referral - sw
Process of sending a patient to another provider for services or consultation that th
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
e referring source believes is outside their scope of practice. This must be approved
sw sw sw sw sw sw sw sw sw sw sw sw sw s
by the insurance company. Meant to cut down on unnecessary services.
w sw sw sw sw sw sw sw sw sw sw
QUESTIONS AND CORRECTS
ANSWERS
Know /Define terms in "Who's Who" in Health Insurance -
sw sw sw sw sw sw sw sw sw
swProvider: is the medical professional who provides the healthcare services to the pa
sw sw sw sw sw sw sw sw sw sw sw sw
tient. In the medical office, this is usually the doctor, nurse practitioner, and physicia
sw sw sw sw sw sw sw sw sw sw sw sw sw
n assistant.
sw sw
Policy Holder: whose name is covered by the insurance company. Ultimately respon
sw sw sw sw sw sw sw sw sw sw sw
sible for payment of the bills. Makes it possible for Dependents (spouse, children, si
sw sw sw sw sw sw sw sw sw sw sw sw sw
gnificant other) of the insured to be covered.
sw sw sw sw sw sw sw
Carrier - is the one that writes and administers the health insurance policy
sw sw sw sw sw sw sw sw sw sw sw sw
Self Insured - sw sw
(A company, usually large) that creates a fund for collection of premiums/
sw sw sw sw sw sw sw sw sw sw sw sw
payments of claims for its employees. The Third Party Administrator is the outside c
sw sw sw sw sw sw sw sw sw sw sw sw sw
ompany that administers the plan, processes the claims, etc. for their employees. Th
sw sw sw sw sw sw sw sw sw sw sw sw
e company assumes the risk of providing health care to their employees.
sw sw sw sw sw sw sw sw sw sw sw
Beneficiary - sw
the person eligible to receive benefits under the health insurance policy.
sw sw sw sw sw sw sw sw sw sw sw
Define Medicare and who is eligible -
sw sw sw sw sw sw
This started in 1965 under President Lyndon Johnson. A federal health insurance e
sw sw sw sw sw sw sw sw sw sw sw sw sw
ntitlement program compliments the Social Security, passed in 1935. The beneficiary
sw sw sw sw sw sw sw sw sw sw
eligibility include individuals 65+, younger individuals with disabilities, and individuals
sw sw sw sw sw sw sw sw sw sw
with end stage renal disease.
sw sw sw sw sw
Four Parts of Medicare -
sw sw sw sw
Medicare, Part A...hospital services, including inpatient hospitalization, Skilled nursin
sw sw sw sw sw sw sw sw sw
g, Home care, hospice care. Patients have a 90 day hospital stay benefit in a given
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw s
wbenefit period (usually one year), plus a 60 day lifetime reserve. Patient must enroll
sw sw sw sw sw sw sw sw sw sw sw sw sw s
wat the time just before or after 65th birthday. Premiums covered under Social Securi
sw sw sw sw sw sw sw sw sw sw sw sw sw
ty.
Medicare Part B....Physician/ sw sw
nurse practitioner services services, outpatient hospital services, hospital and ambula
sw sw sw sw sw sw sw sw sw
,tory surgery, physical and speech therapy, chemotherapy. Patient must be enrolled i
sw sw sw sw sw sw sw sw sw sw sw
n Part A, and then pays monthly premium out of pocket.
sw sw sw sw sw sw sw sw sw sw
Medicare Part C...... Started in 1997, also called Medicare Advantage or Medicare M
sw sw sw sw sw sw sw sw sw sw sw sw
anaged Care. Broader in- sw sw sw
network coverage (more restrictive), lower out of pocket costs vs. Medicare Part B.
sw sw sw sw sw sw sw sw sw sw sw sw sw
Plans to phase this down/maybe out.
sw sw sw sw sw
Medicare Part D......started in 2006. Voluntary drug benefit program. Patient must en
sw sw sw sw sw sw sw sw sw sw sw
roll in a private insurance plan approved by Medicare for Part D. Coverage. A restric
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
ted formulary is provided based on the diagnosis and treatment of a medical conditi
sw sw sw sw sw sw sw sw sw sw sw sw sw
on.
Key players of Medicare and how its works - -
sw sw sw sw sw sw sw sw sw
Federal Government: Congress mandates and Medicare rules and regulations
sw sw sw sw sw sw sw sw
-
Medicare Administrative Agencies: Operational responsibility. Under the Dept. of Hea
sw sw sw sw sw sw sw sw sw
lth and Human Services is CMS (Center for Medicare Services)
sw sw sw sw sw sw sw sw sw
-Non-
Governmental Medicare Agencies...Private companies called intermediaries, who con
sw sw sw sw sw sw sw
tract with CMS to process claims. Also called MACs (Medicare Administrative Contra
sw sw sw sw sw sw sw sw sw sw sw
ctor). Very often a private insurance company as Blue Cross or Aetna may serve as
sw sw sw sw sw sw sw sw sw sw sw sw sw sw s
wintermediaries for Medicare in different sections of the country, since they have the i
sw sw sw sw sw sw sw sw sw sw sw sw sw
nfrastructure in place. sw sw
-Hospitals provide services under Medicare Part A.
sw sw sw sw sw sw
sw
-
Physicians provide services under Medicare Part B...Note that a physician can be a
sw sw sw sw sw sw sw sw sw sw sw sw sw
participating or non- sw sw
participating provider. To be participating, a physician must submit an application for
sw sw sw sw sw sw sw sw sw sw sw
m to Medicare to provide services to beneficiaries. An NPI (National Provider Identifi
sw sw sw sw sw sw sw sw sw sw sw sw
er) number is assigned for billing.
sw sw sw sw sw sw
-
Participating provider sees Medicare beneficiaries and "accepts assignment" which m
sw sw sw sw sw sw sw sw sw
eans that they accept Medicare's fee schedule. Medicare pays 80% of allowable rei
sw sw sw sw sw sw sw sw sw sw sw sw
mbursement, with remaining 20% collected from the patient.
sw sw sw sw sw sw sw sw
-Non-
participating...doctor does not accept assignment. Fee schedule is 95% of fee sched sw sw sw sw sw sw sw sw sw sw sw
ule for participating provider. Payment of the claim sent to patient, not to doctor. Be
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
neficial for doctor to be participating.
sw sw sw sw sw
Define Medicaid, who it covers, basic elements -
sw sw sw sw sw sw sw
provides benefits to low income groups with no or limited health insurance. Federal
sw sw sw sw sw sw sw sw sw sw sw sw sw s
,government provides general guidelines and funding, but Medicaid programs are ad
w sw sw sw sw sw sw sw sw sw sw
ministered by each state. Fee schedule is usually less than Medicare, maybe 75-
sw sw sw sw sw sw sw sw sw sw sw sw
80% of Medicare fee schedule. Usually $3.00 co-
sw sw sw sw sw sw sw
pay. The indigent population, along with low reimbursement makes it unpopular with
sw sw sw sw sw sw sw sw sw sw sw sw
most doctors. Covers basic preventive services, "bare bones coverage"
sw sw sw sw sw sw sw sw
Define Tricare, who it covers, basic elements - -
sw sw sw sw sw sw sw sw
Worldwide health services with military facilities that provides services for the military
sw sw sw sw sw sw sw sw sw sw sw
and their families. Which includes.....active duty.....retired service members,.......activ
sw sw sw sw sw sw sw sw
e/non active/retired National Guard.
sw sw sw
-Tricare provides network (military medical personnel and facilities) and non-
sw sw sw sw sw sw sw sw sw
network .benefits. Only specialized/
sw sw sw
medically necessary services usually provided out of network
sw sw sw sw sw sw sw sw
-
The VA (Veterans Administration) provides acute care, ambulatory, and rehabilitation
sw sw sw sw sw sw sw sw sw s
wservices to veterans. sw sw
-There are also military hospitals (Walter Reed. Bethesda Naval) for active military
sw sw sw sw sw sw sw sw sw sw sw
Types of plans - Fee for Service/Indemnity, PPO, HMO (capitation), HDHP
sw sw sw sw sw sw sw sw sw sw
Fee for Service/Indemnity -
sw sw sw
Health insurance of the 1960's, now rare because it is so expensive. First dollar co
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
verage, usually 80% covered, 20% out of pocket co-
sw sw sw sw sw sw sw sw
insurance. Flexibility to choose any doctor or hospital.
sw sw sw sw sw sw sw
Preferred Provider Organizations (PPO) -
sw sw sw sw
(Has some model features of Fee for Service) Insurance companies contract with n
sw sw sw sw sw sw sw sw sw sw sw sw sw
etworks of providers and hospitals, from which the patient can select. Doctor accept
sw sw sw sw sw sw sw sw sw sw sw sw
s/
insurance and patient pays a lower rate, in exchange for joining the network. Going
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
"out of network" is much more costly for the patient. Primary care gatekeeper is usu
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
ally not required.
sw sw
Health Maintenance Organization (HMO) -
sw sw sw sw
focuses on preventive care. Primary care physician is the gatekeeper in the networ
sw sw sw sw sw sw sw sw sw sw sw sw sw
k established by the insurance carrier, which means that referrals are required to se
sw sw sw sw sw sw sw sw sw sw sw sw sw
e a specialist, and pre-
sw sw sw sw
authorizations to be admitted to a hospital. Going out of network usually prohibited.
sw sw sw sw sw sw sw sw sw sw sw sw sw
Per some plans, the primary care doctor paid on a captitated basis, which means a
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
set fee, is received per member per month, to manage the care of the patient with
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
a focus on prevention. Kaiser Permanente is a nationally known one.
sw sw sw sw sw sw sw sw sw sw
, (HDHP) High Deductible Health Plans/Consumer Directed Plans: -
sw sw sw sw sw sw sw
Due to high healthcare costs, many companies are shifting costs to their employees
sw sw sw sw sw sw sw sw sw sw sw sw sw
through higher deductibles. To go with the "stick" of higher deductibles, the 'carrot"
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
is allowing individuals and companies to put "pre-
sw sw sw sw sw sw sw
tax" dollars in accounts to help pay for the high front end deductibles.
sw sw sw sw sw sw sw sw sw sw sw sw
Laws have been passed by Congress, where Health Savings Accounts (HAS), Healt
sw sw sw sw sw sw sw sw sw sw sw
h Reimbursement Accounts (HRA) and Flexible Spending Accounts (FSA) have bee
sw sw sw sw sw sw sw sw sw sw
n created.
sw
In 2011, pre-
sw sw
tax medical savings accounts under high deductible account allowances are now $1,
sw sw sw sw sw sw sw sw sw sw sw
200 per individual, and $2,400 for a family. Insurance benefits start after the deducti
sw sw sw sw sw sw sw sw sw sw sw sw sw
ble is met. sw sw
Premium - sw
Paid monthly in return for coverage under the policy. Price based on contracted be
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
nefits in the health policy. Most employers pay a portion of the premium, with the e
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
mployee paying a portion based on a designated payroll deduction.
sw sw sw sw sw sw sw sw sw
Co-Payment - sw
Required payment to the provider or institution at the time of service, per the policy
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
. Very common for patient to pay a $10-$25 in a doctor's office for this.
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
Deductible - sw
First dollar out of pocket payment required by some plans before the insurance co
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
mpany pays. The patient, not insurance company at risk for payment of services at t
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
he beginning of the plan year.
sw sw sw sw sw
Insurance payment - sw sw
Portion of health services paid by the insurance carrier. Amount paid is in the insur
sw sw sw sw sw sw sw sw sw sw sw sw sw sw sw
ance policy. sw
Co-Insurance - Service balance that remains after the deductible and co-
sw sw sw sw sw sw sw sw sw sw
pay has been paid, which is the responsibility of the insured.
sw sw sw sw sw sw sw sw sw sw
Exclusions - sw
services not covered in the policy (common are laser eye surgery, cosmetic surgery
sw sw sw sw sw sw sw sw sw sw sw sw sw
, fertility treatments.)
sw sw
Referral - sw
Process of sending a patient to another provider for services or consultation that th
sw sw sw sw sw sw sw sw sw sw sw sw sw sw
e referring source believes is outside their scope of practice. This must be approved
sw sw sw sw sw sw sw sw sw sw sw sw sw s
by the insurance company. Meant to cut down on unnecessary services.
w sw sw sw sw sw sw sw sw sw sw
