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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 nonprofit integrated delivery system






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






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






4. 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






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






6. 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






7. Privately purchased individual or group health insurance policies designed to supplement Medicare coverage






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






9. 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






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






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






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

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






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 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






16. 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






17. 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.






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






19. 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.






20. 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.






21. Is the individual directing the selection - preparation - or administration of tests - medication - or treatment






22. Individually identifiable health information






23. Individually identifiable health information






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






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






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






27. 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






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






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






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






31. A federal law that requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated






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






33. 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






34. Medical services provided on an outpatient basis






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






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






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






39. 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






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






41. 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






42. 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






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






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






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






46. 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






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






48. 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.






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






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