This document provides training materials on insurance fundamentals and health plans. It defines key insurance terminology like HMOs, PPOs, and POS plans. It explains how to find health plan contract summaries online and what information they contain. Common insurance terms are defined, including different types of insurance payors, plans, and individual vs. group coverage. The document compares different types of managed care plans and their key features. It also summarizes Medicare including the different parts and supplemental plans. Medicaid eligibility and managed care options are overviewed. Important healthcare acronyms are listed. Case scenarios are provided to demonstrate how to handle different patient insurance situations.

1. Training and
Development
Program
Insurance Fundamentals
Module 1 and 2
By Idalmis Fernandez and James
Gonzalez

2. Learning Objective
 Define
health insurance terminology and
concepts
 Describe the most common types of
managed care products and programs
 Understand health insurance
documents, forms and publications
 Identify and resolve common health
insurance problems that impact clinical
practice

3. Health BIBLE
CONTRACT SUMMARY
Finding the Contract Summary Online:
Log on to UMMG website:
www.umdoctors.com
Click on “Employee Intranet” - top greymenu bar
Pop-up login window username and
password (enter UM sign-in Outlook
email domain name and password)
Click on “Healthplan Contract
Summary”
The Contract Summary has information
about …
UMMG Contracts
Effective dates
UChart Registration Coverage
Contract limitations
Authorization Policies
Type of managed care product
Level of care participation
Primary
Routine Specialty
Tertiary
Telephone numbers
Contracted hospitals and labs
Specialty Networks participation

4. Insurance Terms


INSURANCE TERMS
Insurance: Is protection against a loss. In health insurance, an insurer guarantees to pay a sum
of money to health professionals or facilities for prevention or treatment of a health problem.


Health Insurance Payors - A company licensed to sell health insurance (i.e.
AvMed, BCBS, Cigna, Humana, etc…)


Health Insurance Plan - A defined program of insurance with specific benefits, specific costs and
specific rules (i.e. AvMed H.MO., BCBS P.P.O., Cigna E.P.O., Humana Open access, etc…)


Indemnity Plans - A health care plan that allows members to see virtually any doctor that they
choose and to receive coverage for services without any authorization. Popular, prior to the
widespread introduction of Managed Care Plans


Managed Care Plans - A health care payment system that attempts to manage utilization and
reduce healthcare costs (HMO/PPO/POS/EPO)


Individual Insurance or Self-insured – An individual who is not part of an employee group or
organization that purchases individual insurance coverage



Group Insurance – An organization or company that is contracted with an insurance
company to provide coverage for employees or organization members.
(e.g. University of Miami group plan)

5. UChart’sVisual Analysis

6. Health Plan Comparison
Product
Type
HMO
EPO
Exclusive Provider
Health Maintenance Organization
Organization
Gatekeeper HMO
A health plan that
functions like a PPO,
A health plan in which the patient
in which patients
receives medical services that are
must visit a physician
delivered by a Primary Care Physician in their Network, but
(PCP)
do NOT have
coverage for out-ofnetwork services

PCP selection required

No Out-of Network benefits or

No PCP
coverage (exception only in
required
case of emergency)

Self-refer or

PCP referrals are required to
direct access
see specialists
to specialists

Health plan authorization is

No Out-of
required for most medical
Network
services
benefits

Co-payments for doctor’s visits

Co-payments
and Coinsurance
HMO OPEN ACCESS
Allows direct access or self-referral
(“referral free”) to specialist
For some HMO Open Access plans a
PCP selection may be required but no
referral is needed to see Specialist.
PPO
Preferred Provider
Organization
A plan that contracts
with a limited network
of physicians and
facilities to provide
services to patients at
a discounted rate




POS
Point of Service
A health plan works
like an HMO with an
out-of-network or
“PPO” option.
Indemnity
Indemnity
Traditional Plan
A plan that allows
members to see
virtually any doctor
When an In-Network
that they choose to
physician is selected:
receive coverage
for services without

Works like an
No PCP
authorization
HMO (PCP,
required
Fee-forReferral, etc…) 
Self-refer or
Service type

In-Network
direct access to
plan
benefits
specialists

NO PCP
applied
Out-of Network
requirement
benefits

Not
When an Out-ofDeductible, Co- Network physician is
restricted to
payments and selected:
network of
Co-insurance
physicians

Works like a

NO
PPO
Authorization
required

Out-ofNetwork
benefits
applied
POS Open Access direct access or selfreferral (“referral
free”) to specialist for
in-network and outof-network
coverage.

7. Medicare
MEDICARE
Medicare is a Federal entitlement program, authorized by Congress to provide medical benefits
to individuals who are over 65, who meet certain criteria. Federal workers and anyone eligible
for Social Security benefits are automatically enrolled in Medicare Part A. Enrollment in Part B is
voluntary and requires a monthly premium.
The following are eligible for Medicare services:
• People age 65 or older
• Some people under age 65 with disabilities
• People with End-Stage Renal Disease (ESRD), which is permanent kidney failure requiring
dialysis or a kidney transplant
• Afflicted spouses and afflicted dependent children of workers who pay Social Security
Benefits.
• Retired federal employees enrolled in the CSRS (Civil Service Retirement system) and their
spouses over 65.
The Center for Medicare and Medicaid Services (CMS) is the federal agency responsible for
managing the Medicare program.
For additional information on Medicare visit www.medicare.gov or www.ssa.gov

8. The Social Security number followed by one of these codes is often referred to as a claim number. We assign these codes once you apply
for benefits. These letter codes may appear on correspondence you receive from Social Security or on your Medicare card. They will never
appear on a Social Security card.
For example, if the wage earner applying for benefits and your number is 123-45-6789, then your claim number is 123-45-6789A. This
number will also be used as your Medicare claim number, once you are eligible for Medicare.
Code
A
Identification
Primary claimant (wage earner)
B
B1
Aged wife, age 62 or over
Aged husband, age 62 or over
B2
B3
Young wife, with a child in her care
Aged wife, age 62 or over, second claimant
B5
Young wife, with a child in her care, second claimant
B6
BY
Divorced wife, age 62 or over
Young husband, with a child in his care
C1-C9
Child - Includes minor, student or disabled child
D
D1
Aged Widow, age 60 or over
Aged widower, age 60 or over
D2
D3
Aged widow (2nd claimant)
Aged widower (2nd claimant)
D6
Surviving Divorced Wife, age 60 or over
E
E1
E4
E5
F1
F2
F3
F4
F5
F6
Widowed Mother
Surviving Divorced Mother
Widowed Father
Surviving Divorced Father
Parent (Father)
Parent (Mother)
Stepfather
Stepmother
Adopting Father
Adopting Mother
HA
Disabled claimant (wage earner)
HB
Aged wife of disabled claimant, age 62 or over
M
Uninsured – Premium Health Insurance Benefits (Part A)
M1
Uninsured - Qualified for but refused Health Insurance Benefits (Part A)
T
Uninsured - Entitled to HIB (Part A) under deemed or renal provisions; or Fully insured who have elected
entitlement only to HIB
TA
Medicare Qualified Government Employment (MQGE)
TB
W
W1
W6
MQGE aged spouse
Disabled Widow
Disabled Widower
Disabled Surviving Divorced Wife

9. Medicare
Medicare Part A





Inpatient hospital
Skilled Nursing
Facility
Hospice care
Home health care
Blood transfusions
Medicare Part B
Medicare Supplemental Plan
(Medigap)
Medicare Advantage (Medicare Replacement Plans)




Outpatient hospital
Physician services
Diagnostic Tests
Durable Medical
Equipment
An insurance plan that covers
the patient’s Medicare
deductible and 20% coinsurance obligations
Advantage Plans include:

Ambulance services
Policies may be purchased:
Offers wider range of benefits.



Health Maintenance Organization (HMO)
Preferred Provider Organization Plans (PPO)
Private Fee-for-Service Plans (PFFS)
Offer prescription drug benefits
Enrollment is automatic for
those who turn 65 and
have worked the required
amount of time paying
into Social Security or
Railroad Retirement.
Enrollment is voluntary and
requires a monthly premium
payment.

Individually

May be paid through
an employer-sponsored
program, for retirees of
a company
*Annual deductible $163
*Reimburses 80% of covered
services
*Patient responsible for
deductible and 20% coinsurance
Patients with an Advantage Plan do not need a supplemental
plan
All supplemental plans cover
the following core services:



Part B - 20% coinsurance
Hospital co-insurance
from day 61-90
Additional hospital days
after the reserve days
Examples of 2nd payors are:
Mail Handlers Insurance, BCBS
, AARP
HOSPITAL Inpatient
MANAGED CARE
PHYSICIANS Outpatient
SECONDARY PAYOR
MEDICARE
IMPORTANT: For Medicare beneficiaries who continue to work after age 65 and maintain coverage under an employer health plan, if the
employer group has more than 20 members,
the group plan is primary for the employee and spouse and Medicare is the secondary
payer.

10. Medicaid
MEDICAID
The Medicaid program provides health coverage to low-income families
individuals.
and to some elderly and disabled
Medicaid
Basic Eligibility
Aid to Families and
Dependent Children
(AFDC)
Children and adults
who meet Medicaid
(AFDC) eligibility
criteria
Supplemental Security
Income
(SSI)
Provides payments to
low income, elderly,
blind and disabled
individuals
Pregnant Women
and Children
Provides coverage to:
*Pregnant Women
*Children up to age 6 - eligible if family
income is below 133% of poverty line
*Children age 6-11 - family income is
below 100% poverty line
*Children age 12-18 - family income is
below AFDC levels
Medicare
Beneficiaries
Supplemental to
Medicare Part B.
For low income
Medicare
beneficiaries

11. Medicaid Managed Care Eligible recipients may choose to receive health services
through, Medicaid Provider Access System (MediPass), Medicaid HMOs, Provider Service
Network (PSN) or the Children's Medical Service Network (CMSN)
Managed Care
MediPass
Medicaid HMOs
Provider Service Network
(PSN)
Children’s Medical
Services
Network(CMSN)
(N OT AN I NSURANCE
P LAN )
Definition
MediPass is a statewide provider network run by Florida Medicaid. Form
of managed care designed to:

Ensure access to Primary Care

Reduce inappropriate utilization

Control program costs
Primary Care Providers are responsible for providing or arranging for the
recipient's primary care and for referring the recipient for other
medically necessary services (e.g. Specialty Care).
Under this program, Florida contracts with HMOs to provide prepaid
services to Medicaid recipients. There are currently 14 HMOs providing
Medicaid services throughout Florida.
Product Names
N/A
A Provider Service Network (PSN) is an integrated health care delivery
system owned and operated by Florida physician groups.
The principal health insurance provider for children with special health
care need (CSHCN) due to long term chronic physical, behavioral or
emotional conditions

Medicaid (Title 19) eligible CSHCN up to age 20

Florida KidCare (Title 21) eligible CSHCN up to age 19

Safety Net – eligible CSHCN who do not qualify for Medicaid or
KidCare
Children’s Medical
Services (CMSN)
Network

12. KidCare Program
Through Florida KidCare, the state of Florida offers health
insurance for children from birth through age 18, even if one
or both parents are working. It includes four different parts.
When you apply for the insurance, Florida KidCare will check
which part your child may qualify for based on age and
family income.
MEDIKIDS: children ages 1 through 4.
HEALTHY KIDS: children ages 5 through 18.
CHILDREN’S MEDICAL SERVICES NETWORK: children birth
through 18 who have special health care needs.
MEDICAID: children birth through 18. A child who has other
health insurance may still qualify for Medicaid.

13. Healthcare
Acronyms
•CMS - Centers for
Medicare and
Medicaid
Services
VETERANS ADMINISTRATION & TRICARE
•Veterans Administration Health Care System –
The VA system operates hospitals, outpatient clinics and nursing homes, nationwide. The program is
intended to provide comprehensive health care to those veterans with severe service-related
disabilities. For other veterans, the program is intended to provide care for service-connected
disabilities and to act as a safety net for veterans with limited access to health care. The VA
administers a health benefits program that covers services defined by the individual veteran's benefit
eligibility.
For additional information, visit the VA System website at
http://www.va.gov/health_benefits/
•TRICARE Military (Civilian Health and Medical Programs of the Uniformed Services)
This program of health care delivery provides insurance coverage for active duty military
personnel, their dependents and military retirees. The TRICARE program is managed by the military in
partnership with civilian contractors. (i.e. Humana)
The program provides two options:
1. TRICARE Prime: managed-care option, similar to a civilian HMO plan.
2. TRICARE Standard (PP0): a fee-for-service option, offering comprehensive health care
coverage, for those not enrolled in TRICARE Prime. Standard offers the greater flexibility in
choosing a provider, but it will also involve greater out-of-pocket expenses (annual deductible, copayments and co-nsurance) for the patient.
TRICARE Extra: can be used by any TRICARE eligible beneficiary, who is not active duty, and not
enrolled in
Prime. Extra is essentially a supplemental plan for an for TRICARE Standard members
who want to save on out-of- pocket expenses by making an appointment with a TRICARE
Prime network provider.
Several of these programs require the services of a primary care case manager. For more details
visit the TRICARE website at - http://www.tricare.osd.mil/
• JCAHO - Joint
Commission on
Accreditation of
Healthcare
Organizations
•OSHA Occupational
Safety and Health
Administration
•SNF - Skilled
Nursing Facility
•PHT - Public
Health Trust
•SCHIP - State
Children's Health
Insurance Program
•WIC - Women's,
Infants, and
Children Program
at the US Dept
of Agriculture
•HIPPA - Health
Insurance
Portability
and Accountability
Act
•CDC - Center for
Disease Control
and
Prevention
•VA - Veterans
Affairs

14. CASE SCENARIO
Directions: In groups, discuss and then present how you would handle the following scenarios:
1. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After
asking for demographic information, you ask the patient for insurance coverage. Patient has CarePlus (noncontracted HMO). What should the receptionist tell the patient?
2. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After
asking for demographic information, you ask the patient for insurance coverage. Care PPO (non- contracted PPO).
What should the receptionist tell the patient?
3. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After
asking for demographic information, you ask the patient for insurance coverage. Patient has Mutual of Omaha
Indemnity plan. What should the receptionist tell the patient?
4. You are the receptionist at a UM clinic and a patient calls wanting an appointment for a UM Physician. After
asking for demographic information, you ask the patient for insurance coverage. Patient has Care POS, (noncontracted POS) and is authorized to see UM physician as in-network. What should the receptionist tell the patient?

15. Levels of Medical Care
PRIMARY CARE (PCP) - total health of the
patient (e.g. Internal Medicine, Family
Medicine, Pediatrics, OB/GYN)
SECONDARY CARE (SPECIALTY) - routine
specialty care (e.g.
Dermatology, Cardiology, Surgery, Ortho/Reh
ab etc…)
TERTIARY CARE - is complex medical
treatment rarely available in the
community, outside of academic medical
centers (i.e. Specialist referrals to
Specialist, transplants, revisions).

16. SINGLE CASE NEGOTIATIONS (SCN)
The University of Miami conducts a SCN when the patient has a noncontracted HMO and needs specific care that is not commonly found in the
community.
WE DO NOT DO SINGLE CASE NEGOTIATIONS FOR:
•Non-contracted PPO - members have out of network benefits
•Indemnity plans
•Self pay patients
If the patient needs a SCN do not give them an appointment, have them call
their HMO health plan representative who will call our nurse case manager to
coordinate the authorization. If the service is approved the patient will call back
to schedule an appointment with an authorization number.

17. Via telephone calls, faxes or
email from:
PCPs
Specialists
Insurance Company
Hospital Admissions
UMMG Departments
Physician Referral Office - PRO
BPEI appointments
UMMG case
management notified of
need for Single case
Notification from
insurance company?
YES
Letter of Agreement
is generated
Letter is signed?
NO
Appropriate
departments are
notified
YES
Create case in
UChart System

18. Best Practices
•
•
•
•
•
•
Always verify member eligibility
and plan benefits
Always check to see if referral or
authorization is required for the
service
Always collect member copayment or deductible
Always send consult report back to
referring physician
Always use the Contract Summary
as a reference tool
Always treat patients with respect
and courtesy
•
•
•
•
Always accept all contracted
plans, non-contracted PPOs and
indemnity plans
Always notify Health Plan Relations
of problems, issues and changes with
any of the insurance plans (#243-7141)
Always notify UMMG Credentialing
office (#243-7688) of
changes, additions and deletions to
faculty practice
Always notify UMMG Business Dev.
(#243-5273) of problems with online
services (i.e. Medifax, Availity, jhsdomc.org, unitedhealthcareonline, et
c…)

19. On-line Activity
Directions: Answer the following questions using the Contract Summary online.
1. AvMed
•At what LEVEL OF CARE do we accept patients?
•List the UChart Registration Coverage
•List one CONTRACT LIMITATION.
•List one AUTHORIZATION POLICY.
•What Specialty Networks contract for this health plan?
2. BCBS – Health Options
•At what LEVEL OF CARE do we accept patients?
•List the UChart Registration Coverage
•List one CONTRACT LIMITATION.
•List one AUTHORIZATION POLICY.
•What Specialty Networks contract for this health plan?
3. Cigna
•At what LEVEL OF CARE do we accept patients?
•List the UChart Registration Coverage
•List one CONTRACT LIMITATION.
•List one AUTHORIZATION POLICY.
•What Specialty Networks contract for this health plan?
4. Humana
•At what LEVEL OF CARE do we accept patients?
•List the UChart Registration Coverage
•List one CONTRACT LIMITATION.
•List one AUTHORIZATION POLICY.
•What Specialty Networks contract for this health plan?

20. 5. JHS Division of Managed Care (JMH Health Plan)
•At what LEVEL OF CARE do we accept patients?
•List the UChart Registration Coverage
•List one CONTRACT LIMITATION.
•List one AUTHORIZATION POLICY.
•What Specialty Networks contract for this health plan?
6. Aetna
•At what LEVEL OF CARE do we accept patients?
•List the UChart Registration Coverage
•List one CONTRACT LIMITATION.
•List one AUTHORIZATION POLICY.
•What Specialty Networks contract for this health plan?
7. Neighborhood Health Partnership - NHP
•At what LEVEL OF CARE do we accept patients?
•List the UChart Registration Coverage
•List one CONTRACT LIMITATION.
•List one AUTHORIZATION POLICY.
•What Specialty Networks contract for this healthplan?
8. Vista Health Plan of South Florida
•At what LEVEL OF CARE do we accept patients?
•List the UChart Registration Coverage
•List one CONTRACT LIMITATION.
•List one AUTHORIZATION POLICY.
•What Specialty Networks contract for this healthplan?

21. Module 2 UCHART

22. Scheduling Registration
Work Flow
http://www.youtube.com/watch?v=oypYhRyiCg8
Private Link
Video Demonstration

23. UChart Sched/Reg Flow
Universal Registration
Appointment Entry Screen
Specific Appointment Registration

24. Difference between Hospital Visits and
Non Hospital.
The Difference between

25. Guarantors
 Who

is the Guarantor for Medical Bills ?
Who the guarantor is for medical bills depends on a couple things. An
adult that obtains medical care is responsible for their own medical bills,
so they are the guarantor. If a child is taken for medical care then there
are a couple things that can determine who is guarantor. The parent
who takes the child for care normally signs a paper that states they are
responsible for any expenses. Of course, if there are court orders stating
a certain parent is responsible for all medical expenses, then it can be
enforced.

26. Guarantor Summary Screen
Example of Multiple Accounts

27. Guarantors Coverage & Add Add’l
Coverage Info for Specific Account

28. Coverage Summary Example
with multiple Guarantors

29. Reg-Appointment Screen
Universal
Specific Appt
registration

30. POS-22 and POS-11
Hospital Accounts vs. Visit Accounts

31. Universal Checklist

32. Reg-Appt Specific CheckList

33. UChart Coverage Field

34. THE END!