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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. 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






2. 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






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






4. 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






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






6. A patient claim is eligible for medicare and medicaid






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






8. 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






9. A rule - condition - or requirement






10. 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






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 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






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






14. 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.






15. 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.






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






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






18. 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.






19. A willful act by an employee of taking possession of an employer's money






20. Is a provider who sends the patients for testing or treatment






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






22. 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






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 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)






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






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






27. Is a provider who sends the patients for testing or treatment






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






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






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






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






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






33. 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






34. 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






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






36. 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






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






38. Medical services provided on an outpatient basis






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






40. A nonprofit integrated delivery system






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






42. 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






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






44. 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






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






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






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






48. 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






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






50. A privileged communication that may be disclosed only with the patient's permission.