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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 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






2. 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






3. Usually described as a comprehensive inpatient program for those who have experienced a serious illness - injury or disease but who do not require intensive hospital services. This includes infusion therapy - respiratory care - cardiac services - wou






4. An entity that transmits health information in electronic form in connection with a transaction covered by HIPAA. The covered entity may be a helath care coverage carrier such as Blue Cross - a health care clearinghouse through which claims are submi






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






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






7. American Medical Association






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






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






10. A document signed by the patient that is needed for use and disclosure of protected health information for purposes other than treatment - payment or health care operations






11. 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.






12. 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






13. 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






14. Individually identifiable health information






15. A flexible health care plan that allows patients to choose using the panel of providers within the HMO network or to utilize the services of non HMO providers






16. 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






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






18. 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






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






20. Is the individual directing the selection - preparation - or administration of tests - medication - or treatment






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






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






23. A nonprofit integrated delivery system






24. 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






25. 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






26. A nonprofit integrated delivery system






27. Standards of conduct generally accepted as a moral guide for behavior.






28. A physician - the majority of whose practice is devoted to internal medicine - family/general practice and pediatrics. An ob/gyn sometimes is considerd a primary care physician depending on coverage






29. A monthly fee paid by the insured for specific medical insurance coverage






30. A patient claim is eligible for medicare and medicaid






31. Individually identifiable health information






32. 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






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






34. Unauthorized release of information






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






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






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






38. 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






39. Billing for services not performed






40. 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.






41. Managed care product that offers enrollees a choice among options when they need medical services - rather than when they enroll in the plan. Enrollees may use providers outside the managed care network - but usually at higher cost






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






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






44. 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






45. Coverage for the treatment obtained from a non-participating provider. Typically - it requires payment of a deductible and higher co-payments and co-insurance than for treatment from a participating provider






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






47. A rule - condition - or requirement






48. 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.






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






50. Medicare's method of paying acute care hospitals for inpatient care