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






2. 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






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






4. 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






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






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






7. 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






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






9. 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






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






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






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






13. 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






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






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






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






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






18. 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






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






20. 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






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






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






23. Integrating benefits payable under more than one health insurance.






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






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






26. 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






27. 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






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






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






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






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






32. 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)






33. A patient claim is eligible for medicare and medicaid






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






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






36. Medical services provided on an outpatient basis






37. A rule - condition - or requirement






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






39. 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






40. 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






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






42. Unauthorized release of information






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






44. 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.






45. Medical services provided on an outpatient basis






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






47. 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






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






49. Individually identifiable health information






50. 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