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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. 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.






2. 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.






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






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






5. A rule - condition - or requirement






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






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






8. 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






9. 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






10. 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






11. 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






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






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






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






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






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






17. 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.






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






19. 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






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






21. A process of meeting regulations - recommendations - and expectations of federal and state agencies that pay for health care services and regulate the industry






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






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






24. 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






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






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






27. 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






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






29. 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






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






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

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






33. 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.






34. 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






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






36. 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






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






38. Is the individual directing the selection - preparation - or administration of tests - medication - or treatment






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






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






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






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






43. 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






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






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






48. A notice to the insurance company that a person received care covered by the plan. A claim is also a request for payment






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






50. Individually identifiable health information