Glossary
Tags
- ACA
- ACA Marketplace
- ACA subsidies
- CHIP
- CMS
- ESRD
- Extra Help
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- FPL
- FQHC
- FSA
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- Medicaid (rare)
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- Medicare Advantage
- Medicare Part A
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- Medicare Part D
- Medicare coordination
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- NOMNC
- Original Medicare
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- Part A
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- QLE
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- Section 1115
- Silver Plan
- Silver plan
Appeal
A formal request to have a health insurance company or government program review a decision regarding coverage or services, such as a denial of payment for a medical service.
A formal request to have a health insurance company or government program review a decision regarding coverage or services, such as a denial of payment for a medical service.
Benefit Verification
The process of confirming an individual’s eligibility and benefits for health services through Medicaid, Medicare, or private insurance. This ensures coverage and payment for services.
The process of confirming an individual’s eligibility and benefits for health services through Medicaid, Medicare, or private insurance. This ensures coverage and payment for services.
Coordination of Benefits (COB)
A process used when a patient is covered by more than one insurance plan. It determines which insurance plan pays first and helps prevent overpayment for services covered by both policies. COB applies to Medicare, Medicaid, and private insurance.
A process used when a patient is covered by more than one insurance plan. It determines which insurance plan pays first and helps prevent overpayment for services covered by both policies. COB applies to Medicare, Medicaid, and private insurance.
Disenrollment
The process of voluntarily or involuntarily terminating coverage under a health insurance plan, such as Medicare, Medicaid, or CHIP. Disenrollment may occur if a beneficiary no longer meets eligibility requirements or chooses to switch plans.
The process of voluntarily or involuntarily terminating coverage under a health insurance plan, such as Medicare, Medicaid, or CHIP. Disenrollment may occur if a beneficiary no longer meets eligibility requirements or chooses to switch plans.
Judicial Review
A legal process in which courts review decisions made by federal or state agencies regarding healthcare programs like Medicare or Medicaid. Beneficiaries may request judicial review if they disagree with a ruling on coverage or eligibility.
A legal process in which courts review decisions made by federal or state agencies regarding healthcare programs like Medicare or Medicaid. Beneficiaries may request judicial review if they disagree with a ruling on coverage or eligibility.
Notice of Medicare Non-Coverage (NOMNC)
A formal notice that Medicare beneficiaries receive when their care is set to end, explaining that Medicare will no longer cover certain services. Beneficiaries have the right to appeal the decision if they disagree with the termination of coverage.
A formal notice that Medicare beneficiaries receive when their care is set to end, explaining that Medicare will no longer cover certain services. Beneficiaries have the right to appeal the decision if they disagree with the termination of coverage.
Prior Authorization
A requirement that certain healthcare services or medications must be approved by the health insurance provider before they are provided. Medicare, Medicaid, and ACA plans may require prior authorization for procedures or high-cost drugs.
A requirement that certain healthcare services or medications must be approved by the health insurance provider before they are provided. Medicare, Medicaid, and ACA plans may require prior authorization for procedures or high-cost drugs.
Referral
A written order from a primary care doctor for a patient to see a specialist or receive certain medical services. Many Medicare Advantage, Medicaid, and ACA plans require a referral before seeing a specialist or undergoing specialized tests.
A written order from a primary care doctor for a patient to see a specialist or receive certain medical services. Many Medicare Advantage, Medicaid, and ACA plans require a referral before seeing a specialist or undergoing specialized tests.
Timely Filing Limit
The period within which a claim for medical services must be submitted to an insurance provider to be eligible for reimbursement. Medicare, Medicaid, and private insurance plans have specific timely filing limits, typically ranging from 90 days to one year.
The period within which a claim for medical services must be submitted to an insurance provider to be eligible for reimbursement. Medicare, Medicaid, and private insurance plans have specific timely filing limits, typically ranging from 90 days to one year.
Utilization Management
A process used by health insurance providers to evaluate the necessity and efficiency of healthcare services. It includes practices like prior authorization, step therapy, and case reviews to ensure appropriate use of medical resources. Common in Medicare Advantage, Medicaid, and ACA plans.
A process used by health insurance providers to evaluate the necessity and efficiency of healthcare services. It includes practices like prior authorization, step therapy, and case reviews to ensure appropriate use of medical resources. Common in Medicare Advantage, Medicaid, and ACA plans.
Voluntary Disenrollment
The process by which an individual chooses to leave a health insurance plan, such as Medicare Advantage, Medicare Part D, or a Medicaid managed care plan. Beneficiaries may disenroll during the appropriate enrollment periods or under special circumstances.
The process by which an individual chooses to leave a health insurance plan, such as Medicare Advantage, Medicare Part D, or a Medicaid managed care plan. Beneficiaries may disenroll during the appropriate enrollment periods or under special circumstances.