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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 monthly fee paid by the insured for specific medical insurance coverage






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






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






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






5. 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






6. 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






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






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






9. A list of the amount to be paid by an insurance company for each procedure service






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






11. A patient claim is eligible for medicare and medicaid






12. A nonprofit integrated delivery system






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






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






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






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






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






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






19. 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






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






21. Billing for services not performed






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






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






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






25. 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.






26. Data related to the treatment and progress of the patient that can be released only when written authorization of the patient or guardian is obtained.






27. 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






28. 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






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






30. 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






31. 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






32. Health Information Portability and Accountability Act






33. 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






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






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






36. 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






37. 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






38. 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






39. 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






40. This law mandates reporting - disclosure of grievance and appeals requirements and financial standards for group life and health. Self insured plans are regulated by this law






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






42. 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






43. 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






44. Is the individual directing the selection - preparation - or administration of tests - medication - or treatment






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






46. American Medical Association






47. Is the provider who renders a service to a patient






48. Individually identifiable health information






49. 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






50. 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.