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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 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






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






4. 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






5. A notice to the insurance company that a person received care covered by the plan. A claim is also a request for payment






6. 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.






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






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






9. 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.






10. Medical services provided on an outpatient basis






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






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






13. 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






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






15. 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.






16. 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






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






18. 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






19. 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






20. 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)






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






22. 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






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. 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






25. 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






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






27. American Medical Association






28. 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






29. The amount of actual money available to the medical practice






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






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






32. The transmission of information between two parties to carry out financial or administrative activities related to health care.






33. A nonprofit integrated delivery system






34. 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






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






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






37. 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






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






39. 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.






40. Individually identifiable health information






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






42. 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






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






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






45. 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






46. 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.






47. A rule - condition - or requirement






48. 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






49. 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






50. 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