Sports Medicine One
Common Insurance Terminology / 1

Common Insurance Terminology

  1. ______-the maximum amount, according to the individual policy, that insurance will pay for each procedure or service performed.
  2. ______-a person eligible to receive the benefits of a specific policy or program.
  3. ______- Services that an insurer, government agency, or health care plan offers to pay for an insured individual.
  4. ______- The process in which the attending physician or agent coordinates the care given to a patient by other health care providers and/or community organizations.
  5. ______- A form sent to an insurance company requesting payment for covered medical expenses
  6. ______- A filed claim with all the necessary information that may be immediately processed
  7. ______- A legally binding agreement between an insurance company and a physician describing the duties of both parties
  8. ______- A provision in an insurance policy requiring the policyholder to pay a specified percentage of each medical claim
  9. ______- The average fee charged for a specified service or procedure in a defined geographic area
  10. ______- The amount owed by the insured on a yearly basis before the insurance company will begin to pay for services rendered
  11. ______- A person legally eligible for benefits based on his or her relationship with the policyholder
  12. ______- Specified medical services, disorders, treatments, diseases, and durable medical equipment that are listed as uncovered or not reimbursable in an insurance policy
  13. ______- An insurance report accompanying all claim payments that explains how the insurance company processed a claim
  14. ______- A comprehensive listing of the maximum payment amount that an insurance company will allow for specified medical procedures performed on a beneficiary of the plan
  15. ______- The primary care physician assigned by the insurer that oversees the medical care rendered to a patient and initiates all specialty and ancillary services

Work bank for this page:

allowable charge / claim / clean claim
dependent / exclusions / benefits
case management services / beneficiary / explanation of benefits (EOB)
fee schedule / customary fee / gatekeeper
copayment / deductible / contract
  1. ______-A health care provider who has entered into a contract with an insurance company to provide medical services to the beneficiaries of a plan. The provider agrees to accept the insurance company’s approved fee and will only bill the patient for the deductible, copayment, and uncovered services
  2. ______- The person who takes out the medical insurance policy
  3. ______- A periodic payment made to an insurance company by an individual policy
  4. ______- An independent organization that collects premiums, pays claims, and provides administrative services within a health care plan
  5. ______- Usual, customary, and reasonable charge that represents the maximum amount an insurance company will pay for a given service based on geographical averages
  6. ______- The primary mechanism of payment for medical services in the United States
  7. ______- A contract between the insurance company and policyholder
  8. ______- The most traditional form of billing for health care in which the provider charges the patient or a third-party payer a fee for services provided
  9. ______- A form of reimbursement used by managed care providers in which members make a standard payment each month regardless of how much service is rendered to the member by the provider
  10. ______- General health insurance that covers illness, hospitalizations, and emergency care
  11. ______- Insurance coverage that pays remaining medical bills once the athlete’s general health insurance plan has made its payment

Word bank for this page:

UCR allowable charge / premium / participating provider
medical insurance / indemnity plan / capitation
policyholder / third party administrator / reimbursement
secondary insurance / primary insurance