Medical Insurance Ch 9

Document of eligible members of a capitated plan registered with a particular PCP for a monthly period.

Generally, preauthorization for hospital admission or outpatient procedure.

Document that modifies an insurance contract.

Type of health plan combining high-deductible insurance, usually a PPO with a relatively low premium, and a funding option to pay for patients out-of-pocket expensesup to the deductible.

A part of a standard health plan that is changed under a negotiated employer-sponserednplan; also refers to subcontracting of coverage by a health plan.

Organization hired by a payer to evaluate the medical necessity of procedures before they are provided to a member of a plan.

A federal law that provides incentives and protection against litigation for companies that set up employee health and pension plans.

Blue Cross and Blue Shield Plan in the community where the subscriber has contracted for coverage.

Protection against the risk of large losses or severly adverse claims experience; may be included in a participating provider's contract with a plan or bought by a self-funded plan.

Contract under which a third-party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.

A Blue Cross and Blue Shield program that provides benefits for plan subscribers who are away from their local areas.

The national licensing agency of Blue Cross and Blue Shield plans.

Federal law requiring employers with more than twenty employees to allow employees who have been terminated for reasons other than gross misconduct to pay for coverage under the employer's group health plan for 18 months after termination.

Periodic verification that a provider or facility meets professional standards of a certifying organization; physician credentialing involves screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence.

History of health insurance coverage for calculation of COBRA benefits.