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






2. 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






3. 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






4. An organization of provider sites with a contracted relationship that offer services






5. Billing for services not performed






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






7. 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






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






9. 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






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






11. 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






12. 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.






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






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






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






16. A group of physicians or other health care providers who have a contractual agreement to provide services to subscribers on a negotiated fee-for-services or capitated basis






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






18. An independent person or corporate enitity(third party) that administers group benefits - claims and administration for a self-insured company or group






19. 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.






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






21. 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






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






23. 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






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






25. 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






26. The state of treating privately or secretly - and not disclosing to other individuals or for public knowledge - the patient's conversations or medical records.






27. A document that is not required before physicians use or disclose protected health information for treatment - payment - or routine health care operations of the patient. (For other purposes - see Authorization form)






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






29. 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






30. 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






31. Individually identifiable health information






32. 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






33. American Medical Association






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






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






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






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






38. 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






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






40. 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






41. 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.






42. The state of treating privately or secretly - and not disclosing to other individuals or for public knowledge - the patient's conversations or medical records.






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






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






45. 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






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






47. 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






48. 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






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






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