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Medical Coding And Billing Clinical Vocab

Instructions:
  • Answer 50 questions in 15 minutes.
  • If you are not ready to take this test, you can study here.
  • Match each statement with the correct term.
  • Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.
1. A managed care system that allows the patient to only select from a defined panel of providers - who are reimbursed on a modified fee-for-service method






2. A term used to refer to the commonly charged or prevailing fees for health services within a geographic area






3. An organization of provider sites with a contracted relationship that offer services






4. A group of primary care physicians who have joined together to share the risk of providing care to their patients who are covered by a given health plan






5. Data related to the treatment and progress of the patient that can be released only when written authorization of the patient or guardian is obtained.






6. Is the provider who renders a service to a patient






7. A health care plan that stipulates that the patient must use a medical provider who is under contract with the insurer for an agreed on fee






8. Paperwork for the insurance company that is required from the PCP to send a patient to see a medical specialist for treatment






9. A document that is not required before physicians use or disclose protected health information for treatment - payment - or routine health care operations of the patient. (For other purposes - see Authorization form)






10. The mode of electronic transmission (e.g. Internet - extranet - leased phone or dial-up phone lines - fax modems).






11. Also known as out-of-network provider. A healthcare provider who has not contracted with the carrier of a health plan to be a participating provider of healthcare






12. A group of physicians or other health care providers who have a contractual agreement to provide services to subscribers on a negotiated fee-for-services or capitated basis






13. A list of the amount to be paid by an insurance company for each procedure service






14. The member who holds an insurance policy providing medical coverage in return for a fixed monthly fee






15. Under HIPAA - regulations related to the security of electronic protected health information that - along with regulations - related to electronic transactions and code sets - privacy - and enforcement - compose the Administrative Simplification prov






16. A provider whose opinion or advice about evaluation or management of a specific problem is requested by another physician






17. A person - who on behalf of the covered entity - performs or assists in the performance of a function or activity involving the use or disclosure of individually identifieable health information.






18. A document that is not required before physicians use or disclose protected health information for treatment - payment - or routine health care operations of the patient. (For other purposes - see Authorization form)






19. A practice of some health insurers to deny coverage to individuals for a certain period for health conditions that already exist when coverage is initiated






20. A provider who has contracted with the health plan to deliver medical services to covered persons. This includes hospitals - pharmacies or a physician who has contractually accepted the terms and conditions as set forth by the health plan






21. Integrating benefits payable under more than one health insurance.






22. Under HIPAA - a document given to the patient at the first visit or at enrollment explaining the individual's rights and the physician's legal duties in regard to protected health information.






23. The portion of payments for covered health services required to be paid by the patient - including co-payments - co-insurance and deductible






24. A form signed by the patient showing insurance plans assigned and their billing priority. This form allows the hospital to bill insurance on the patient's behalf and receive payment directly from the payor






25. American Medical Association






26. A group of physicians or other health care providers who have a contractual agreement to provide services to subscribers on a negotiated fee-for-services or capitated basis






27. A notice to the insurance company that a person received care covered by the plan. A claim is also a request for payment






28. A portion of the covered expenses that an insured individual must pay before inusrance coverage with co-insurance goes into effect. Deductibles are usually based on a calander year






29. American Medical Association






30. A health insurance enrollee chooses to see an out of network provider without authorization






31. A clinic that is owned by the HMO and the physicians are employees of the HMO






32. A privileged communication that may be disclosed only with the patient's permission.






33. The release - transfer - provision of access to - or divulging in any other manner of information outside the entity holding the information.






34. A fee is considered 'Reasonable' if it is both usual and customary or if it is justified because there is a complex problem involved






35. A patient claim is eligible for medicare and medicaid






36. Any data that identify an individual and describes his or her health status - age - sex - ethnicity - or other demographic characteristics - whether or not that information is stored or transmitted electronically.






37. Prior approval from a health care plan administrator to receive reimbursement for surgery and other procedures to be performed






38. The dates of healthcare services were provided to the beneficiary






39. A request to an insurance company or group medical plan by another inusrance company or medical plan to find out whether other coverage exists






40. Approval or consent by a primary physician for patient referral to ancillary services and specialists






41. The person responsible for payment of premiums or whose employment is the basis for eligibility for membership in an HMO or other health plan






42. An authorization directing the insurer to make payment directly to a provider of benefits - such as a physician or dentist - rather than to the insured






43. A rule - condition - or requirement






44. Medical staff member who is legally responsible for the care and treatment given to a patient.






45. A review of the need for inpatient hospital care - completed before the actual admission






46. Physicians - hospitals and other healthcare providers that an HMO - PPO or other managed care network has selected to provide care for its members






47. A complex technical issue not within the scope of the health care provider's role; refers to instances when state law takes precedence over federal law.






48. What the insurance company will consider paying for as defined in the contract.






49. A provider of medical or health services and any other person or organization who furnishes bills or is paid for health care in the normal course of business.






50. The period of time that payment for Medicare inpatient hospital benefits are available