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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. 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






2. A physician who specializes in a specific area of medicine - such as cardiology - oncology - urology






3. A rule - condition - or requirement






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






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






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






7. Individually identifiable health information






8. 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.






9. A rule - condition - or requirement






10. 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






11. A patient claim is eligible for medicare and medicaid






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






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






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






15. 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






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






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






18. 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






19. 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






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






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. 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.






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






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






25. 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






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






27. 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.






28. A managed care plan in which a range of health care services are made available to plan members for a predetermined fee per member






29. 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






30. 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






31. 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






32. 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






33. 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






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






35. 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.






36. 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






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






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






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






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






42. Unauthorized release of information






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






44. 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.






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






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






47. A nonprofit integrated delivery system






48. 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






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






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







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