NHA CCMA Health care systems and
settings (Insurance fundamentals) Exam
Prep
Third-party payers -
\ organisations that pay for healthcare services on behalf of the patients.
Deductibles -
\Montetary amount patients must pay to the provider for health care services before the
services (insurance) begins to pay.
Certificate of coverage -
\Letter that documents the nature and length of coverage with the plan.
Formulary -
\A list of drugs approved for coverage. It is subdivided into two or more tiers with each
tier having a different level of coverage.
Eligibility -
\To determine if a patient is qualified to receive coverage/paid insurance policy
guidelines.
Insurance claims -
\Bills that medical offices send to insurance companies on behalf of patients for medical
services.
Assignment of benefits -
\When patients signs this it authorizes the insurance company to pay directly to the
provider.
Fee schedule -
\A list of charges for each services they provide such as a physical exam or flu shot.
Verfication of benefits (VOB) -
\The process to determine the patient's eligiblity
Point of service (POS) -
\Offers a primary HMO provider network & a secondary ppo provider network. Allowing
patients to choose which plan to use at the time of the service.
Allowed amount -
\The amount that insurance companies consider to be an appropriate fee.
settings (Insurance fundamentals) Exam
Prep
Third-party payers -
\ organisations that pay for healthcare services on behalf of the patients.
Deductibles -
\Montetary amount patients must pay to the provider for health care services before the
services (insurance) begins to pay.
Certificate of coverage -
\Letter that documents the nature and length of coverage with the plan.
Formulary -
\A list of drugs approved for coverage. It is subdivided into two or more tiers with each
tier having a different level of coverage.
Eligibility -
\To determine if a patient is qualified to receive coverage/paid insurance policy
guidelines.
Insurance claims -
\Bills that medical offices send to insurance companies on behalf of patients for medical
services.
Assignment of benefits -
\When patients signs this it authorizes the insurance company to pay directly to the
provider.
Fee schedule -
\A list of charges for each services they provide such as a physical exam or flu shot.
Verfication of benefits (VOB) -
\The process to determine the patient's eligiblity
Point of service (POS) -
\Offers a primary HMO provider network & a secondary ppo provider network. Allowing
patients to choose which plan to use at the time of the service.
Allowed amount -
\The amount that insurance companies consider to be an appropriate fee.
