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Advance Beneficiary Notice (ABN)
o A form provided to the patient when the provider believes Medicare will probably not
pay for services received
Allowed Amount
o The maximum amount a third-party payer will pay for a particular procedure or service
Copayment
o An amount of money that is paid at the time of medical service
Coinsurance
o A policy provision in which the policyholder and the insurance company share the cost
of covered medical services in a specified ratio.
Deductible
a specific amount of money a patient must pay out of pocket before the
insurance carrier begins paying
Explanation of Benefits
o A statement from the insurance carrier detailing what was paid, denied, or reduced in
payment; also contains information about amounts applied to the deductible,
coinsurance, and allowed amounts
Participating Provider (PAR)
o Providers who agree to write off the difference between the amount charged by the
provider and the approved fee established by the insurer
Medicare
o Generally covers patients age 65 and older by Part A (hospitalization) or Part B (routine
medical office visits) benefits
Tricare
o Authorizes dependents of military personnel to receive treatment from civilian
providers at the expense of the federal government
CHAMPVA
o Covers surviving spouses and dependent children of veterans who died as a result of
service-related disabilities
Medicaid
o Provides health insurance to the medically indigent population through a cost-sharing
program between federal and state governments for those who meet specific eligibility
criteria
Managed Care
o An umbrella term for plans that provide health care in return for preset scheduled
payments and coordinated care through a defined network of providers and hospitals
Workers Compensation
o Protects wage earners against the loss of wages and the cost of medical care resulting
from an occupational accident or disease as long as the employee is not proven
negligent
What is in Section 1 of the CMS-1500 Form?
o It contains the address of the insurance carrier and is located at the top of the form
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