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






2. Individually identifiable health information






3. Billing for services not performed






4. Health Information Portability and Accountability Act






5. 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.






6. The period of time that payment for Medicare inpatient hospital benefits are available






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






8. 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






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. 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






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






12. A patient claim is eligible for medicare and medicaid






13. 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.






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






15. 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






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






17. 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






18. A nonprofit integrated delivery system






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






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






21. The Medicare program that pays for a protion of the cost of physicians' services - outpatient hospital services and other related medical and health services for voluntarily insured aged and disabled individuals






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






23. 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






24. 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






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






26. 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






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






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






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






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






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






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






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






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






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






36. A person - who on behalf of the covered entity - performs or assists in the performance of a function or activity involving the use or disclosure of individually identifieable health information.






37. 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






38. 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






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






40. Individually identifiable health information






41. 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.






42. 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






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






44. 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






45. The person responsible for payment of premiums or whose employment is the basis for eligibility for membership in an HMO or other health plan






46. American Medical Association






47. 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






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






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






50. A request to an insurance company or group medical plan by another inusrance company or medical plan to find out whether other coverage exists