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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 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






2. Billing for services not performed






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






4. Authorization given by a health plan for a Member to obtain services form a healthcare provider - most commonly required for hospital services






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






6. 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






7. 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






8. A federal law that requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated






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






10. An individual designated ot help the provider remain in compliance by setting policies and procedures in place - and by training and managing the staff regarding HIPAA and patient rights; usually the contact person for questions and complaints.






11. The transmission of information between two parties to carry out financial or administrative activities related to health care.






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

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






14. A federal law that requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated






15. 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.






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






17. 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.






18. 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






19. 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






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






21. 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






22. 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






23. American Medical Association






24. 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






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






26. Medical services provided on an outpatient basis






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






28. A health care provider that is not employed by the HMO and does not belong to a medical group owned or managed by the HMO






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






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






31. 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






32. Any healthcare services - that are determined by the insurance plan to be either; not generally accepted by informed healthcare professionals in the U.S. as efective in treating the condition - illness or diagnosis for which their use is proposed; or






33. Health Information Portability and Accountability Act






34. American Medical Association






35. A structure for classifying outpatient services and procedures for purpose of payment






36. Someone who is eligible for or receiving benefits under an insurance policy or plan






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






38. Medical services provided on an outpatient basis






39. Medical equipment which: can withstand repeated use - is used to serve a medical purpose - and appropriate for use in the home. Examples include hospital beds - wheelchairs and oxygen equipment






40. 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)






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. Is the provider who renders a service to a patient






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






44. The transmission of information between two parties to carry out financial or administrative activities related to health care.






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






46. A nonprofit integrated delivery system






47. 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






48. 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






49. Privately purchased individual or group health insurance policies designed to supplement Medicare coverage






50. A written and documented request for reimbursement for an eligible expense to the insurance company in a correct and timely manner