MOA Unit 7 (Chapter 27) Key Terms

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Managed Care

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A system that helps people get health care at a lower cost by working with certain doctors and hospitals. Includes referrals and precertification.

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Referrals

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When a primary care doctor sends a patient to a specialist for specific care.

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Precertification

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Getting approval from the insurance company before receiving certain medical services.

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Patient’s Billing Record

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Contains information like patient details, insurance information, services provided, charges, payments, and adjustments.

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Patient Financial Obligations

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The amount a patient has to pay, including deductibles, coinsurance, and copayments.

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Third-Party Plans

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Insurance plans provided by companies other than the patient or provider, like private insurance companies, Medicare, and Medicaid. Information required includes patient details, insurance information, services provided, and charges.

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Steps for Filing a Claim

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Verify coverage, complete claim form, attach necessary documents, and submit to the insurer.

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Managed Care Requirements for Patient Referral

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Includes getting a referral from a primary care doctor and preauthorization from the insurance company.

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Verification of Eligibility

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Checking a patient's insurance coverage and benefits before providing services.

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Preauthorization

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Getting approval from the insurance company to make sure a service is covered and necessary.