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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. 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






2. 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.






3. 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






4. 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.






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






6. 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






7. 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






8. 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






9. Billing for services not performed






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






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






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






14. 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.






15. 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






16. 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.






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






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






19. 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






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






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






23. The condition of being secluded from the presence or view of others.






24. A nonprofit integrated delivery system






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






26. 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






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






28. A patient claim is eligible for medicare and medicaid






29. Health Information Portability and Accountability Act






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






31. 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






32. 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






33. American Medical Association






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






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






36. 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.






37. 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






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






39. 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






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






41. A patient claim is eligible for medicare and medicaid






42. 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






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






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






45. 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






46. 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






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






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. American Medical Association






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