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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. 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






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






3. 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






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






5. A rule - condition - or requirement






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






7. 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






8. 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






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






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






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






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






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






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






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






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






18. Health Information Portability and Accountability Act






19. 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






20. 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






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






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






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






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






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






26. 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






27. 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






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






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






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






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






32. 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






33. American Medical Association






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






35. 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.






36. 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.






37. 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.






38. 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






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. 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.






41. 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






42. Medical services provided on an outpatient basis






43. 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






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






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






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






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






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. Is the provider who renders a service to a patient






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