Medical Terminologies

a signed agreement between a provider and Aetna or a provider and third party.

• Negotiated Rate

• Contract

• benefit level

• cost share

A group of providers in multiple specialties in a specific geographic area.

• Cost Share

• Contract

• benefits

• Network

A member's financial responsibility for medical costs.

• Cost Share

• Contract

• Network

• Benefit

A referral is valid for 1 year.

• True

• False

The dollar amount over what the participating provider billed vs. what the contracted rate is. The provider can't bill the member of the overage amount.

• Referral

• Capitation

• Write-Off

• Precertification

A process of getting approval for specific services where medical necessity needs to be proven.

• Write-Off

• Precertification

• Contract

• Balance Bill

The difference between the billed charge and the amount allowed when no contract is used is called Balance bill.

• True

• False

The lowest level of benefits that have the highest member cost share.

• Participating provider

• Nonparticipating provider

• Preferred Expense

• Nonpreferred Expense

Fee-For-Service is a method of payment where a provider performs a service and is then paid a fee.

• True

• False

A method of payment where a provider is paid a fixed amount based on the number of members they serve.

• Palpitation

• Capitalism

• Capitation

• Caltivation