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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 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






2. 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






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






4. 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






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






6. 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






7. 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






8. Programs designed to reduce unnecessary medical services - both inpatient and outpatient






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






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






11. 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






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






13. 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






14. Under HIPAA - regulations related to the security of electronic protected health information that - along with regulations - related to electronic transactions and code sets - privacy - and enforcement - compose the Administrative Simplification prov






15. 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






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






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






18. 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






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






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






21. 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






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






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






24. 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.






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






26. 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






27. Under HIPAA - regulations related to the security of electronic protected health information that - along with regulations - related to electronic transactions and code sets - privacy - and enforcement - compose the Administrative Simplification prov






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

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






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






31. 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






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






33. Billing for services not performed






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






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. Medical services provided on an outpatient basis






37. 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






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






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






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






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






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






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






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






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






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






47. A monthly fee paid by the insured for specific medical insurance coverage






48. A specific period of time in which employees may change insurance plans and medical groups offered by their employer and have the new insurance effective at a later date






49. 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






50. 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