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






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






3. Unauthorized release of information






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






5. A provider of medical or health services and any other person or organization who furnishes bills or is paid for health care in the normal course of business.






6. 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






7. 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






8. Verbal or written agreement that gives approval to some action - situation - or statement.






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

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






11. 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






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






13. 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






14. 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






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






16. A monthly fee paid by the insured for specific medical insurance coverage






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






18. 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.






19. The dates of healthcare services were provided to the beneficiary






20. A monthly fee paid by the insured for specific medical insurance coverage






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






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






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






24. 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






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






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






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






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






29. 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






30. 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






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






32. 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






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






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






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






36. 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






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






38. 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






39. 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






40. 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)






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






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






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






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






45. 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






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






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






48. The dates of healthcare services were provided to the beneficiary






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






50. A rule - condition - or requirement