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






2. 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






3. 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.






4. 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






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






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






7. A rule - condition - or requirement






8. 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






9. 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






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






11. Individually identifiable health information






12. 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






13. A provision that apples when a person is covered under more than one group medical program






14. 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






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






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






17. A provision that apples when a person is covered under more than one group medical program






18. 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






19. A group of primary care physicians who have joined together to share the risk of providing care to their patients who are covered by a given health plan






20. 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






21. Billing for services not performed






22. 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.






23. 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






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






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






26. Any and all transations in which health care information is accessed - processed - stored - and transferred using electronic technologies.






27. 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






28. 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.






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






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






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






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






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






34. American Medical Association






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






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






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






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






39. 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






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






41. 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






42. A patient claim is eligible for medicare and medicaid






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






44. 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






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






46. Unauthorized release of information






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






48. 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






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






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