Changing the way you learn

Question	Answer
Case Management	Process of eligibility determination and coordination of services for person receiving multiple healthcare services
Peer review organizations	Medicare-sponsored organizations that perform quality control, investigatory, patient education functions
Medically necessary	Physician-status provider determination that a healthcare intervention is required
Spend down	Process where person with potential Medicaid eligibility uses up assets to a certain level to gain eligibility for the program
Fee for service	Payment mechanisms for health care whereby provider is paid amount of money for each procedure performed
Beneficiary	Recipient of benefits from insurance contract
Capitation	Payment mechanism for health care where provider is paid a flat flee for each covered member in a health plan per month
Access	Ability to obtain a healthcare service when you need it
Prospective payment	Form of healthcare payment where providers are paid a set fee or rate prior to delivery of services
Dual eligibility	Persons who qualify for Medicare and Medicaid coverage
Benefit period	Length of time from day of admission to hospital to 60 days post-hospital or SNF discharge
Cost-based reimbursement	Retrospective method of healthcare financing whereby provider reports costs of providing care and is paid by an insurer
Medically needy eligibility	State option qualification for Medicaid based on demonstrated medical need or income level

Insurance and Reimbursement

	Created by luisa.yu almost 11 years ago