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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 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.






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






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






4. A rule - condition - or requirement






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






6. 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






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






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






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






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






11. A rule - condition - or requirement






12. Health Information Portability and Accountability Act






13. 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






14. 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






15. A patient claim is eligible for medicare and medicaid






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






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






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






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






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






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






23. Any and all transations in which health care information is accessed - processed - stored - and transferred using electronic technologies.






24. 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






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 health care provider that is not employed by the HMO and does not belong to a medical group owned or managed by the HMO






27. A nonprofit integrated delivery system






28. 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






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






30. 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






31. 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.






32. A nonprofit integrated delivery system






33. A group of primary care physicians who have joined together to share the risk of providing care to their patients who are covered by a given health plan






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






35. 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






36. 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)






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

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38. 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.






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






40. 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






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






42. 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






43. 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






44. A willful act by an employee of taking possession of an employer's money






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






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






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






48. 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






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






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







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