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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 maximum amount a plan pays for a covered service






2. 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






3. 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






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






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






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






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






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






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






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






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






13. 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






14. 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






15. 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






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






17. 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.






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






19. A managed care plan in which a range of health care services are made available to plan members for a predetermined fee per member






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






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






22. 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






23. 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






24. A nonprofit integrated delivery system






25. 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






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






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






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






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






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






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






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






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

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34. 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






35. 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






36. 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.






37. 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






38. 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






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






40. 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






41. The period of time that payment for Medicare inpatient hospital benefits are available






42. Billing for services not performed






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






44. 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






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






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






47. 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)






48. 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






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






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

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