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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. 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






2. Someone who is eligible for or receiving benefits under an insurance policy or 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. Paperwork for the insurance company that is required from the PCP to send a patient to see a medical specialist for treatment






5. 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






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






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






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






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






10. 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






11. 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






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






13. 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






14. Any part of an individual's health information - including demographic information collected from the individual - that is created or received by a covered entity.






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






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






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






18. 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






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






20. 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.






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






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






23. A willful act by an employee of taking possession of an employer's money






24. 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






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






26. 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






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






28. Health Information Portability and Accountability Act






29. Unauthorized release of information






30. 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






31. Individually identifiable health information






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






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


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






35. Medical services provided on an outpatient basis






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






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






38. 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.






39. 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.






40. 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






41. 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






42. Medical services provided on an outpatient basis






43. 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






44. 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






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






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






47. 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






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






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






50. An insurance plan requirement in which you or your primary care physician need to notify your insurance company in advance about certain medical procedures in order for those procedures to be considered a covered expense