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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. 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






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






3. 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






4. 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.






5. American Medical Association






6. Individually identifiable health information






7. Customs - rules of conduct - courtesy - and manners of the medical profession






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






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






10. 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






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






12. 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






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






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






15. 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






16. 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






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






18. The release - transfer - provision of access to - or divulging in any other manner of information outside the entity holding the information.






19. 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






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






21. 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






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






23. American Medical Association






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






25. 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






26. 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






27. A nonprofit integrated delivery system






28. A provider whose opinion or advice about evaluation or management of a specific problem is requested by another physician






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






30. 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






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






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






34. 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






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






36. 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






37. 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






38. A specific period of time in which employees may change insurance plans and medical groups offered by their employer and have the new insurance effective at a later date






39. Physicians - hospitals and other healthcare providers that an HMO - PPO or other managed care network has selected to provide care for its members






40. 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






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






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






43. 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






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






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






46. Medical services provided on an outpatient basis






47. A rule - condition - or requirement






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






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






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