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






2. 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






3. Unauthorized release of information






4. 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.






5. 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






6. 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






7. 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






8. 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






9. 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






10. 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






11. 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






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






13. The hospital classification and reimbursement system that groups patients by diagnosis - surgical procedures - age - sex and presence of complications.

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






15. A nonprofit integrated delivery system






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






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






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






19. 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






20. 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






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






22. Under HIPAA - a document given to the patient at the first visit or at enrollment explaining the individual's rights and the physician's legal duties in regard to protected health information.






23. 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






24. 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






25. Health Information Portability and Accountability Act






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






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






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






29. Individually identifiable health information






30. 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.






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 rule - condition - or requirement






33. 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






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






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






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






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






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






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






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






41. 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






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






43. 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






44. 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






45. 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






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






47. Any part of an individual's health information - including demographic information collected from the individual - that is created or received by a covered entity.






48. 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.






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