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






2. A patient claim is eligible for medicare and medicaid






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






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






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






6. 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






7. 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






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






9. 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.






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






11. 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






12. 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)






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






14. The condition of being secluded from the presence or view of others.






15. Verbal or written agreement that gives approval to some action - situation - or statement.






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






17. 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






18. An insurance plan requirement in which you or your primary care physician need to notify your insurance company in advance about certain medical procedures in order for those procedures to be considered a covered expense






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






20. 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.






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






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






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






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






26. Medical services provided on an outpatient basis






27. 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






28. 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






29. 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






30. 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






31. A nonprofit integrated delivery system






32. Medical services provided on an outpatient basis






33. 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






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






35. 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






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






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






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






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






42. 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






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






44. An individual designated ot help the provider remain in compliance by setting policies and procedures in place - and by training and managing the staff regarding HIPAA and patient rights; usually the contact person for questions and complaints.






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






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. The state of treating privately or secretly - and not disclosing to other individuals or for public knowledge - the patient's conversations or medical records.






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






49. The Medicare program that pays for a protion of the cost of physicians' services - outpatient hospital services and other related medical and health services for voluntarily insured aged and disabled individuals






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