PAR Medical Terminology and Clinical Documentation Flashcards

What does 'PCP' stand for in a managed care insurance plan?

Answer: Primary Care Physician

PCP stands for Primary Care Physician, the provider responsible for coordinating a patient's overall healthcare and issuing referrals to specialists in HMO plans.

What is a 'formulary' in the context of prescription drug benefits?

Answer: A list of prescription drugs covered by an insurance plan, often organized into tiers with different cost-sharing levels

A formulary is an insurance plan's approved list of covered medications, categorized into tiers that determine the patient's copay or coinsurance for each drug.

What does an 'out-of-pocket maximum' mean for a patient?

Answer: The maximum amount a patient must pay in a plan year before insurance covers 100% of covered services

The out-of-pocket maximum is the cap on total cost-sharing a patient pays in a plan year; once reached, the insurer pays 100% of covered in-network costs.

What is a 'network provider' in the context of health insurance?

Answer: A provider who has a contracted agreement with an insurer to provide services at negotiated rates

A network provider has signed a contract with the insurer to accept negotiated rates, resulting in lower out-of-pocket costs for the patient compared to out-of-network providers.

What is 'utilization review' (UR) and how does it affect patient access?

Answer: A process used by insurers to evaluate the medical necessity and appropriateness of services before, during, or after care is provided

Utilization review is the evaluation by payers of whether services are medically necessary and appropriate, and patient access staff must often obtain prior authorization as part of this process.

What does 'place of service' (POS) code indicate on a medical claim?

Answer: The setting where the service was rendered, such as a physician's office, outpatient hospital, or emergency room

The place of service code is a two-digit code on a claim that identifies the setting in which care was delivered, which affects payment rates and coverage rules.