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






2. An independent person or corporate enitity(third party) that administers group benefits - claims and administration for a self-insured company or group






3. Medical services provided on an outpatient basis






4. 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.






5. 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






6. Information consisting of ordinary facts unrelated to the treatment of the patient. The patient's authorization is not required to disclose the data unless the record is in a specialty hospital or in a special service unit of a general hospital - suc






7. A sum of money that must be paid by the patient before the insurance plan pays benefits for services rendered






8. The state of treating privately or secretly - and not disclosing to other individuals or for public knowledge - the patient's conversations or medical records.






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. 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.






11. A management plan composed of policies and procedures to accomplish uniformity - consistency - and conformity in medical record keeping that fulfills offical requirements.






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






13. ABN billing rules permit physicians and other Part B care providers to bill beneficiaries directly when Medicare will not cover services for lack of medical necessity






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






15. The most money you can expect to pay for covered expenses. Once the max out-of-pocket has been met - the health plan will pay 100% of certain covered expenses






16. An intentional misrepresentation of the facts to deceive or mislead another.






17. 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






18. Any and all transations in which health care information is accessed - processed - stored - and transferred using electronic technologies.






19. A physician who is part of am managed care plan that provides all primary health care services to members of the plan






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






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






22. 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






23. 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.






24. This law mandates reporting - disclosure of grievance and appeals requirements and financial standards for group life and health. Self insured plans are regulated by this law






25. American Medical Association






26. Billing for services not performed






27. Is a provider who sends the patients for testing or treatment






28. A provision that apples when a person is covered under more than one group medical program






29. A physician who is part of am managed care plan that provides all primary health care services to members of the plan






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






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






32. Incidents or practices - not usually considered fraudulent - that are inconsistent with accepted sound medical business or fiscal practices.






33. The amount of actual money available to the medical practice






34. The hospital classification and reimbursement system that groups patients by diagnosis - surgical procedures - age - sex and presence of complications.

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35. An insurance policy - plan - or program thay pays second on a claim for medical care. For children covered under two insurance plans - primary coverage will be determined by the Subscriber (mom and dad) whose month of birth is closest to the beginnin






36. The maximum amount a plan pays for a covered service






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






38. 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






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






40. An independent organization that receives insurance claims from the physician's office - performs software edits - and redistributes the claims electronically to various insurance carriers.






41. Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage






42. Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage






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






44. 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.






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






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






47. A process of meeting regulations - recommendations - and expectations of federal and state agencies that pay for health care services and regulate the industry






48. A specific period of time in which employees may change insurance plans and medical groups offered by their employer and have the new insurance effective at a later date






49. 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






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