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






2. 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.






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






4. The release - transfer - provision of access to - or divulging in any other manner of information outside the entity holding the information.






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






6. 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






7. A patient claim is eligible for medicare and medicaid






8. 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






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






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






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






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






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






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






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






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






17. Individually identifiable health information






18. Billing for services not performed






19. 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






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






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






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






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






24. 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






25. Medical services provided on an outpatient basis






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






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 dates of healthcare services were provided to the beneficiary






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






30. 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






31. 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.






32. 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






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






34. 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






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






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






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






38. 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






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






40. 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






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






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






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






44. American Medical Association






45. 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.






46. 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






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






48. 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






49. 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)






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