Type
Crossword
Description

The state pays claims from premiums collected from the members and their employers Self Insured
The amount paid each month for insurance coverage regardless of whether or not the member receives health services Premiums
A flat dollar mount paid for services and products Copay
A set dollar amount paid out of pocket each year for services Deductible
A group of doctors, hospitals and other health care providers contracted with a health insurance plan. Network
Preferred Provider Organization PPO
Consumer Driven Health Plan CDHP
HSA Health Saving Account
FDA approved and equal to the brand-name product in safety, effectiveness, quality, and performance Generic Drug
Participating dentist only with fixed copays Cigna PrePaid
Any dentist, pay less with network providers MetLife DPPO
Vision Carrier Davis Vision
BCBS and Cigna Medical Vendors

Healthcare Vocabulary Crossword

Type
Crossword
Description

A contract with a company where the subscriber pays a regular premium in exchange for a defined set of benefits Health Insurance
Reffered to as family doctor/PCP this person administers routine and preventive care, and makes referrals for specialty services when needed. Primary Care Provider
A provider who focuses on one area of medicine. Like a cardiologist or neurologist Specialist
A contracted, pre-determined dollar amount insurance company requires a patient to pay for a particular medical service. (It requires patients to pay a small amount upfront to deter people from seeking medical care that may not be necessary.) Copay
The contracted rate a health insurance company will pay toward a specific medical service. Allowable Charges
A contracted, pre-determined percentage of the allowable charge that a patient is required to pay for a particular medical service (after the deductible is met and before the out-of-pocket maximum is met). CoInsurance
A pre-determined annual amount patient must pay before insurance begins to cover. Deductible
Annual maximum amount patient is required to pay for in-network medical services per his/her insurance plan contract (typically, copay + coins + deductible) Out of Pocket
The person who is responsible for payment of the monthly premium, or whose employment is the basis for the coverage. Subscriber
A person entitled to health insurance benefits under the subscriber’s plan. Covered Member
Insurance Company Payor
A specific package of benefits negotiated between the company and the employer. Plan
Dates during which the insurance plan is active. Effective Dates
Explanation of Benefits is a statement from the insurance company that details payments and adjustments made for services. EOBs go to both the provider and the patient. EOB
/Response from the insurance company that states no payment will be made. (service could be not covered by the insurance plan, or the insurance company may need more information.) Denial
The order in which the claim is sent to insurance companies. If patient has more than one insurance plan, we must determine which insurance should be billed primary, secondary, etc. Primary: the first insurance company designated to pay toward their allowable charges. Secondary: the second insurance company designated to pay toward their allowable charges. Filing Order
The pathway a patient takes from one provider to another. Referrals may be required by insurance before a patient can be seen by the other provider. Referral
The process whereby a physician must obtain insurance approval before a patient receives certain treatment or drugs (study, test, procedure, surgery.) Authorization

Basics of Health Insurance Crossword

Type
Crossword
Description

An established schedule of fees set for services performed by providers and paid by the patient fee for service
protection in return for periodic premium payments that provides reimbursement of expenses resulting from illness or injury Health insurance
the sum of money paid at the time of medical service; it is a form of coinsurance copayment
provision frequently is found in medical insurance policies whereby the policyholder and the insurance company share the cost of covered losses in a specified ratio coinsurance
Civilian Health and Medical Program of the Veterans Administration known as CHAMPUS
states that when an individual is covered under two insurance policies, the insurance plan of the policyholder whose birthday comes first in the calendar year (month and day, not year) becomes the primary insurance. birthday rule
A term used in managed care for an approved referral authorization
a payment method used by many managed care organizations in which a fixed amount of money is reimbursed to the provider for patients enrolled during a specific period of time, no matter what services were received or how many visits were made. Capitation
a letter or statement from Medicare that describes what was paid, denied, or reduced in payment. EOMB
Pays expenses involved in the care of the teeth and gums Dental care
Protects a person in the event of a certain type of accident, such as an airplane crash Special risk insurance
Often includes benefits for medical expenses payable to individuals who are injured in the insured person’s home or during an automobile accident Liability insurance
Covers a continuum of maintenance and health services for chronically ill, disabled, or mentally retarded individuals Vision care
Provides payment of a specified amount on the insured’s death Life insurance
Pays the cost of all or part of the insured person’s hospital room and board and specific hospital services Hospitalization
a review of individual cases by a committee to make sure services are medically necessary and to study how providers use medical care resources utilization review
40. An insurance term used when a primary care provider wants to send a patient to a specialist referral
periodic (monthly, quarterly, or annual) payment of a specific sum of money to an insurance company for which the insurer, in return, agrees to provide certain benefits premium
person who pays a premium to an insurance company and in whose name the policy is written in exchange for the insurance protection provided by a policy of insurance policyholder
a general practice or nonspecialist provider or physician responsible for the care of a patient for some health maintenance organizations gatekeeper

Medicare Terms Crossword

Type
Crossword
Description

means that your doctor, provider, or supplier must accept the Medicare-approved amount as full payment for covered services Assignment
this visit is available once every twelve months after the first twelve months of Part B coverage AnnualWellnessVisit
the percentage you pay for covered services after you have met your deductible Coinsurance
a fixed amount one pays to receive a medical service, usually at the time of service Copay
the amount one pays annually before the plan begins to pay. This does not apply to services that require a copay Deductible
is long lasting, used for a medical reason, and typically used in an individual's home DME
ESRD EndStageRenalDisease
the plan contract that gives detailed information about the plan, including: what is and is not covered, what an individual pays, etc. EOC
a monthly summary sent to an individual to let them know what services were billed, what was paid by whom, and what amount the individual is responsible to pay. EOB
in this type of plan you can only go to doctors, other health care providers, or hospitals in the plan’s network except in an urgent or emergency situation. HMO
care that is usually given when an individual has decided that they no longer want care to cure terminal illness and/or one’s doctor has determined that efforts to cure an illness aren’t working. Hospice
a status for individuals starting when one is formally admitted to a hospital with a doctor’s order Inpatient
a status for individuals getting emergency department services, observation services, surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit them to a hospital as an inpatient Outpatient
in a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network PPO
the periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage Premium
services to prevent illness or detect illness at an early stage Preventive
the doctor you see first for most health problems PrimaryCareDoctor
a written order from a primary care doctor for a patient to see a specialist or get certain medical services, often required by HMOs Referral

Health Insurance Crossword Puzzle

Type
Crossword
Description

What does the acronym PPO stand for? Preferred Provider Organization
What is the acronym for Health Maintenance Organization? HMO
There are two types of medical billing: Institutional and _______________________. Professional
An __________ is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. EOB
What type of claim form is used by hospitals? UB-04
Another name for a Health Information Specialist is a _________________________ Specialist. Reimbursement
An _____________________________ is a digital version of the traditional paper-based medical record for an individual. The EMR represents a medical record within a single facility, such as a doctor's office or a clinic. EMR
What is the amount you pay for health care services before your health insurance begins to pay? Deductible
A __________ is a fixed amount you pay for a health care service? Copay
A primary care physician is also known as a _______________________. Gatekeeper
What is the abbreviation for out-of-network? OON
What is the abbreviation for in-network? INN
What type of managed care plan lets you choose between an HMO or a PPO each time you need care? POS
How many parts does Medicare have? Four
A 1996 federal law that is sometimes called the "privacy rule", outlining how certain entities can use or disclose personal health information. HIPAA
The reason for the visit or surgery that defines the disease process or injury. Medical Necessity
M48.1 is an example of what type of code? ICD-10
What does UB stand for in UB-04? Uniform Bill
The healthcare system, funded by the U.S. Department of Defense, that active and retired military and their dependents use. Tricare
The entity that reimburses the provider for services. Insurance companies, Medicare, Medicaid, and third-party administrators are all payers in the healthcare industry. Payer
Any health care plan, provider, or service that transmits health care information in an electronic form and is thereby governed by laws and regulations in the handling of such data. It's called a covered _______________? Entity

Medicare 101 Crossword

Type
Crossword
Description

Groups of drugs that have a different cost for each group. Tier
the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. Appeal
An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance. Assignment
A geographic area where a health insurance plan accepts members if it limits membership based on where people live. Service area
A coverage rule used by some Medicare Prescription Drug Plans that requires you to try one or more similar, lower cost drugs to treat your condition before the plan will cover the prescribed drug. Step therapy
A person who has health care insurance through the Medicare or Medicaid programs. Beneficiary
The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. Benefit period
A written order from your primary care doctor for you to see a specialist or get certain medical services. Referral
A request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered. Claim
An amount you may be required to pay as your share of the cost for services after you pay any deductibles. Coinsurance
An amount added to your monthly premium for Part B or a Medicare drug plan (Part D) if you don't join when you're first eligible. You pay this higher amount as long as you have Medicare. There are some exceptions. Penalty
Approval that you must get from a Medicare drug plan before you fill your prescription in order for the prescription to be covered by your plan. Prior authorization
The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay. Deductible
A type of Medicare prescription drug coverage determination, a drug plan's decision to cover a drug that's not on its drug list or to waive a coverage rule Exception
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Formulary
A complaint about the way your Medicare health plan or Medicare drug plan is giving care. Grievance
Health care that you get when you're admitted to a health care facility, like a hospital or skilled nursing facility. Inpatient care
The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. Network

Health Insurance Crossword

Type
Crossword
Description

A system of health care in which patients agree to visit only certain doctors and hospitals Managed care
The acronym for Health Maintenance Organization. HMO
Also known as a primary care physician. Gate Keeper
What is the amount you pay for health care services before your health insurance begins to pay? Deductible
A sum paid to cover money that has been spent or lost. Reimbursement
A federal law that is sometimes called the "privacy rule". HIPAA
What type of claim form is used by a hospital? UB04
Meaning of PPO. Preferred Provider Organization
Having inadequate insurance coverage. Underinsured
The insured pays a share of payment made against a claim. Coinsurance
A federal system of health insurance for those requiring financial assistance. Medicaid
Federal health insurance program for people 65 years or older. Medicare
Dental benefits Employer Sponsored Coverage
A payment owed by the person insured at the time a covered service is rendered, covering part of the cost of the service. Copayment
Provides health care and financial protection. Universal Health Insurance
M48.1 is an example of what type of code? ICD104
Organization paying for some serious treatments people need. Third Party System
Subscription medical, less restrictive than HMO. PPO
Focus solely on preventative care. Preventative Care
Government pays for all health cost. Single Payer System
Not covered by insurance. Uninsured
Premium cost and medical expenses by health care plan. Cost Sharing

Medical Coding and Billing Crossword

Type
Crossword
Description

health plan carrier
reimburse policyhoders for medical sevices indemnity
list of selected drugs and their dosage formulary
amount paid for an insurance policy premium
document that modifies an insurance contract rider
review of systoms ROS
amount paid at time of service coypayment
amount a person pay, usually annual deductible
free service to other physicians professional courtesy
provider who completes the header of an ABN notifier
provides a higher payment upcoding
not coded at highest level truncated coding
identifies improper codes edits
a condition that remains after an acute illness sequelae
a long duration chronic
severe sysmptoms with a short duration acute

Health Insurance Terms Crossword

Type
Crossword
Description

protection in return for periodic premium payments that provides reimbursement of expenses resulting from illness or injury HealthInsurance
the sum of money paid at the time of medical service; it is a form of coinsurance COPAYMENT
An established schedule of fees set for services performed by providers and paid by the patient Feeforservice
A provision of the Insurance Contract that requires the insured to pay a percentage of all eligible medical expenses that result from sickness or injury. Coinsurance
A term used in managed care for an approved referral authorization
A payment method used by many managed care organizations in which a fixed amount of money is reimbursed to the provider for patients enrolled during a specific period of time, no matter what services were received or how many visits were made. Capitation
An insurance term used when a primary care provider wants to send a patient to a specialist Referral
periodic (monthly, quarterly, or annual) payment of a specific sum of money to an insurance company for which the insurer, in return, agrees to provide certain benefits Premium
A request that an insured or the insured’s health care provider makes to the health plan to pay for a health care service provided to the insured. CLAIM
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. Specialist

Benefits & Eligibility Key Terms Crossword

Type
Crossword
Description

Time period in which the benefits renew beginning January 1st. Calendar Year
Is an area in Facets that is used to provide a quick reference of the patients’ benefits. Access to the patients benefit language is done through Benefit Summary. Benefit Summary
A type of contract between a large group (100 + lives) and WPS. The group maintains a money account in which WPS has access to in which the medical claims are paid from. An ASO group pays WPS to administer their benefits and to pay the medical claims for them. These are commonly referred to as self-funded groups. ASO
A request by an individual (his or her provider) to an individual’s insurance company for the insurance company to pay for services obtained from a health care professional. Claim
The process of an analyst reviewing claims for medical necessity, frequency, etc. Claim Review
Percentage that the insurance company pays for services rendered to the member. Coinsurance
Specific dollar amount that a member must pay for every visit. Copay
The amount that a member must pay before the insurance company will start paying for services. Deductible
A type of plan where there is only one benefit level and referrals are required if the patient is seen by an out of network provider. If a referral is not obtained, the services will not be covered. EPO
A system which holds the eligibility data base and the claim system Facets
A prescription legend drug sold by the pharmaceutical company or other legal entity other than the one holding the original United States patent for that prescription legend drug. Generic Drug
A privacy rule which protects the privacy of individually identifiable health information. HIPAA
Type of managed care plan that requires members to use in-network providers for all their health care needs. There is no coverage for services received from providers who are outside of the HMO’s network, except for emergency care. HMO
A group of doctors, hospitals and other providers contracted to provide services to insured individuals for less than their usual fees. Provider networks can cover large geographic markets and/or a wide range of health care services. If a health plan uses a preferred provider network, insured individuals typically pay less for using a network provider. In-Network
Total amount that WPS will pay for claims over the lifetime of the policy. Lifetime maximum
A medical condition or pre-existing condition noted in the application process and added to the policy as a waiver by Underwriting. The waiver is signed by the member and is part of policy. Benefits will not be available for these conditions unless waiver is removed. Medical Rider
Individual Medicare supplement polices are designed to supplement the benefits available under the original Medicare program. Medicare supplement policies pay a percent of Medicare approved charges that Medicare does not pay. Some Medicare supplement policies will pay for benefits for services after Medicare will no longer pay. Network
A group of providers who have agreed to provide services at a contracted rate. Network
The date a policy goes into effect. Original Effective Date
Describes a provider or health care facility which is not part of a health plan’s network. Insured individuals usually pay more when using an out-of-network provider, if the plan uses a network. Out-of-network
Total amount that a member would pay in a calendar or plan year for services rendered to them. Out of pocket
Primary Care Physician PCP
HIPAA prohibits the sharing of PHI without written permission of the patient. PHI includes but is not limited to medical diagnosis, medical treatment, eligibility for a health plan, health plan premium payments, and health care claim status. When PII is linked with health condition, treatment or payment of healthcare, it becomes PHI in the hands of a covered entity like WPS. PHI
This was created by the federal government to prevent identity theft by improving information security. PII is information that can be used to uniquely identify, contact, or locate a single person or can be used with other sources to uniquely identify a single individual. PII includes but not limited to: Full name, tax identification number, driver’s license number, credit card number, date of birth, address, age, race or gender, and salary or job description. PII
A type of plan where there are two or more benefit levels in which a claim can be paid under. A PPO has a network of preferred providers. If a patient goes to a provider not in their network, the claim will be paid at the lesser level of benefit, called out of network or Tier 2. Typically, a PPO does not have a referral option but can; however, referrals are not required. PPO
A request for a service to be reviewed for the medical necessity prior to the patient receiving the service. This review is recommended vs. required. Preauthorization
A request for an inpatient service prior to the admission. Precertification
The amount of money you and/or your employer pays in exchange for insurance coverage. Premium
Certain services require a medical necessity review prior to the service being provided based on the patient’s benefit language. Some benefit language also indicates that if the medical necessity review is not done prior to the service being provided, then a penalty or a benefit reduction will be applied to that service. Prior Approval
Any person or entity providing health care services, including hospitals, physicians, home health agencies and nursing homes. This is an inclusive term to define any person or entity that delivers medical care. Provider
A type of a contract in which WPS is paid a monthly premium for our services. A risk plan can be a small group, a large group or an individual plan. Risk
Certain benefits required to be covered in commercial health insurance plans by the State. State Mandates
Owned and maintained by other companies and WPS rents the use of these networks to offer more providers to our members . Third-Party Networks
An online resource of corporate wide information including individual departmental information. Olli

Health literacy Crossword

Type
Crossword
Description

to obtain, process, and understand basic health information and services needed to make appropriate health decisions Health literacy
defined as: a doctor of medicine or osteopathy, podiatrist ,etc. Health care providers
physician who provides both the first contact for a person with an undiagnosed health concern Primary care physician
physician whose practice is limited to a particular branch of medicine or surgery, especially one who is certified by a board of physicians. Specialist
specified amount of money that the insured must pay before an insurance company will pay a claim Deductible
an amount to be paid for an insurance policy. Premium
amount of money that a person with health insurance is required to pay at the time of each visit to a doctor or when purchasing medicine Copayment
type of health insurance. Managed health care
account of all medical events and problems Medical history
identification of the nature of an illness or other problem by examination of the symptoms. Diagnosis
Health Insurance Portability and Accountability Act Hipaa
methods and treatments used by unskillful doctors or by people who pretend to be doctors. Quackery