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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 patient claim is eligible for medicare and medicaid






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






3. 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






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






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






6. 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






7. 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






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






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






10. 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.






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






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






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






14. 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






15. 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






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






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






18. A sum of money that must be paid by the patient before the insurance plan pays benefits for services rendered






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






20. 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.






21. 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






22. 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






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






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






25. 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






26. 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






27. Incidents or practices - not usually considered fraudulent - that are inconsistent with accepted sound medical business or fiscal practices.






28. A person who protects the computer and networking systems within the practice and implements protocols such as password assignment - backup procedures - firewalls - virus protection - and contingency planning for emergencies.






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






30. 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






31. 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






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






33. Billing for services not performed






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. American Medical Association






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






37. 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






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






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






40. 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






41. A rule - condition - or requirement






42. 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






43. 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






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






45. 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






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






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






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






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






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