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Medical Coding And Billing Clinical Vocab

Instructions:
  • Answer 50 questions in 15 minutes.
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  • Match each statement with the correct term.
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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 term used to refer to the commonly charged or prevailing fees for health services within a geographic area






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






3. 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






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






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






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






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






8. Unauthorized release of information






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






10. Billing for services not performed






11. 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






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






13. A clinic that is owned by the HMO and the physicians are employees of the HMO






14. 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






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






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






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






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






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






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






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






22. 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






23. 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






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






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






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






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






28. 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.






29. 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






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






31. A clinic that is owned by the HMO and the physicians are employees of the HMO






32. 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






33. Individually identifiable health information






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

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35. 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






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. 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






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






39. 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






40. 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






41. 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.






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






43. 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






44. American Medical Association






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






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






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






48. A nonprofit integrated delivery system






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






50. Unauthorized release of information







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