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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. 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






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






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






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






5. 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.






6. Arrangement consisting of a group of providers who have a contract with an insurer - employer - third party administrator or other sponsoring group.






7. Information consisting of ordinary facts unrelated to the treatment of the patient. The patient's authorization is not required to disclose the data unless the record is in a specialty hospital or in a special service unit of a general hospital - suc






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






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






10. Billing for services not performed






11. Medical services provided on an outpatient basis






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






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






14. 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






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






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






17. Unauthorized release of information






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






19. 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






20. Verbal or written agreement that gives approval to some action - situation - or statement.






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






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






23. 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






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. 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






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






27. 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.






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






29. 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






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






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






32. A physician who is part of am managed care plan that provides all primary health care services to members of the plan






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






34. 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






35. 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






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






37. 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.






38. 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






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






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






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






42. Individually identifiable health information






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






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






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






46. 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.






47. 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






48. 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






49. 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






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