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Type of insurance that does not cover primary care, but covers costs associated with significant illness or injury, such as hospitalization or surgeries.
Major medical
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Organization that provides comprehensive health care services for plan particpants at a fixed rate.
Managed Care
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Provides health coverage for the categorically needy; a federal health cost assistance program.
Medicaid
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Unique 10 digit number assigned to providers to identify them on a CMS 1500 claim form.
National Provider Identification
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Process of obtaining approval for a service through the individual's insurance company by establishing that it is medically necessary.
Preauthorization/ Prior authorization
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Process of determining whether a service is covered under the insured person's plan.
Precertification
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Process of ascertaining the amount the insurance carrier will pay for a specific service.
Predetermination
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A diagnosed and treated health condition that the patient had before obtaining insurance.
Preexisting condition
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A plan allowing the insured person to select physicians, hospitals, and other health care services from an approved list issued by their insurance plan to provide care at a discounted rate.
Preferred Provider Organization (PPO)
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A dollar amount the isured person pays for insurance coverage.
Premium
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The usual, customary, and resonable fees of like providers in the same geographic.
Prevailing fee
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Physician contracted through a specific insurance plan to provide or to coordinate the care of all patients assigned through the insurance carrier.
Primary Care Provider (PCP)
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The entity that pays the second party for the medical bills of the first party (insured ot patient) also known as the third party administrator.
Third Party Payer
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Formerly known as CHAMPUS; health care benefit plans provided by the federal government, primarily for spouses and dependents of service men and women.
TRICARE
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Medical and disability insurance to cover employees in the event of a work-related injury, illness, or death.
Workers' Compensation
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