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






2. Programs designed to reduce unnecessary medical services - both inpatient and outpatient






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






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






5. A review of the need for inpatient hospital care - completed before the actual admission






6. A health insurance enrollee chooses to see an out of network provider without authorization






7. 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






8. 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






9. 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






10. 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






11. 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






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






13. 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






14. American Medical Association






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

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16. 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






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






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






19. 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.






20. 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






21. 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






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






23. 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






24. The Medicare program that pays for a protion of the cost of physicians' services - outpatient hospital services and other related medical and health services for voluntarily insured aged and disabled individuals






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






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. 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






28. 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






29. 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






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






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






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






33. 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






34. Health Information Portability and Accountability Act






35. 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






36. 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






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






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






39. The Medicare program that pays for a protion of the cost of physicians' services - outpatient hospital services and other related medical and health services for voluntarily insured aged and disabled individuals






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






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






42. 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






43. A term used to refer to the commonly charged or prevailing fees for health services within a geographic area






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






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






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






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






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






49. 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






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