NHA CBCS Module 2- Insurance
Eligibility and Other Payer Requirements
capitation - Answer -An agreement with a provider to receive a pre-established payment for health care
services to enrollees over a period of time.
coinsurance - Answer -Predetermined percentage the patient is responsible to pay for covered services
once the annual deductible has been met.
copayment (copay) - Answer -Flat, fixed amount that a patient pays for specific services (e.g., office or
emergency department encounters).
covered benefits - Answer -Services outlined in the policy that are payable by the health plan.
deductible - Answer -Annual amount the patient must pay before the insurance will begin to pay for
covered benefits.
guarantor - Answer -The individual who is responsible for paying any patient responsibility after the
insurance has processed a claim.
, health maintenance organization (HMO) - Answer -A group of contracted providers that agree to the
payment contract for its members.
in-network (INN) - Answer -A provider who has signed an agreement with the insurance plan.
noncovered services - Answer -Services that are not payable by the health plan.
out-of-network (OON) - Answer -A provider who does not have a signed agreement with an insurance
plan.
policyholder - Answer -The individual who signs a contact with a health insurance company.
preferred provider organization (PPO) - Answer -a type of managed care organization where providers
join the network and are considered preferred when a patient seeks treatment.
premium - Answer -The amount a patient pays each month to receive benefits.
electronic medical record (EMR) - Answer -A patient's medical record in a digital format that resides
within a health care organization.
electronic health record (EHR) - Answer -a collective of medical records that is used and shared by more
than one organization or provider.
workers' compensation - Answer -Provides benefits and wages replacements to employees who need
medical care due to a work-related injury.
automobile insurance - Answer -Protects the diver and passengers and pays for medical expenses and
other expenses (wage replacement, rental vehicles) related to an accident.
National Association of Insurance Commissioners (NAIC) - Answer -Identifies the coverage requirements
for auto insurance. Each state develops their own laws as long as the minimum standards are met.
Eligibility and Other Payer Requirements
capitation - Answer -An agreement with a provider to receive a pre-established payment for health care
services to enrollees over a period of time.
coinsurance - Answer -Predetermined percentage the patient is responsible to pay for covered services
once the annual deductible has been met.
copayment (copay) - Answer -Flat, fixed amount that a patient pays for specific services (e.g., office or
emergency department encounters).
covered benefits - Answer -Services outlined in the policy that are payable by the health plan.
deductible - Answer -Annual amount the patient must pay before the insurance will begin to pay for
covered benefits.
guarantor - Answer -The individual who is responsible for paying any patient responsibility after the
insurance has processed a claim.
, health maintenance organization (HMO) - Answer -A group of contracted providers that agree to the
payment contract for its members.
in-network (INN) - Answer -A provider who has signed an agreement with the insurance plan.
noncovered services - Answer -Services that are not payable by the health plan.
out-of-network (OON) - Answer -A provider who does not have a signed agreement with an insurance
plan.
policyholder - Answer -The individual who signs a contact with a health insurance company.
preferred provider organization (PPO) - Answer -a type of managed care organization where providers
join the network and are considered preferred when a patient seeks treatment.
premium - Answer -The amount a patient pays each month to receive benefits.
electronic medical record (EMR) - Answer -A patient's medical record in a digital format that resides
within a health care organization.
electronic health record (EHR) - Answer -a collective of medical records that is used and shared by more
than one organization or provider.
workers' compensation - Answer -Provides benefits and wages replacements to employees who need
medical care due to a work-related injury.
automobile insurance - Answer -Protects the diver and passengers and pays for medical expenses and
other expenses (wage replacement, rental vehicles) related to an accident.
National Association of Insurance Commissioners (NAIC) - Answer -Identifies the coverage requirements
for auto insurance. Each state develops their own laws as long as the minimum standards are met.
