Actions inconsistent with accepted, sound medical business or fiscal practice
Provider accepts as payment in full whatever is paid on the cliam by the payer (except for any copayment and or coinsurance amounts.)
The amount owed to a business for services or goods provided.
Accounts Receivable Aging Report
Shows the status (by date) of outstanding claims from each payer, as well as payments due from patients.
Accounts Receivable Management
Assists Providers in the collection of appropriate reimbursement for services rendered; include functions such as insurance verification/eligibility and preauthorization of services.
Voluntary Process that a healthcare facility or organization (e.g. hospital or manged care plan) undergoes to demonstarte that it has met standards beyond those required by law.
Judicial dispuite resolution process in which an appeals board makes a final determination.
payment correction resulting in additional payment(s) to the provider.
Advance Beneficiary Notice (ABN)
Document that acknowledges patient responsiblity for payment if Medicare denies the cliam.
Also called adverse reaction; the appearance of a pathologic condition due to ingestion r exposure to a chemical substance properly administered or taken.
Also called adverse effect; the appearance of a pathologic condition due to ingestion r exposure to a chemical substance properly administered or taken.
Covering members who are sicker then the general population.
see limiting charge; maximum fee a physician may charge.
The Maximum amount the payer will reimburse for each procedure or service, according to the patients policy.
All Patient Diagnosis-Related Group (AP-DRG)
DRG system adapted for use by third-party payers to reimburse hospitals for inpatient care provided to non-Medicare beneficiaries (e.g. Blue Cross Blue Shield, commercial health plans, TRICARE); DRG assignment is based on intensity of resources.
All Patient Refined Diagnosis-Related Group (ARP-DRG)
Adopted by Medicare in 2008 to reimburse hospitals for inpatient care provided to Medicare beneficiaries; expanded originial DRG system (based on intensity of resources) to add two subclasses to each DRG that adjusts Medicare inpatient hospital reimbursement rates for severity of illness (SOI) (extent of physiological decompensation or organ system loss of function) and risk of mortality (ROM) (likelihood of dying); each subclass, in turn, is subdivided into four areas: (1) minor, (2) moderate, (3) major, (4) extreme.
Ambulance Fee Schedule
Payment system for ambulance services provided to Medicare Beneficiaries.
Ambulatory Payment Classification (APC)
Prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required.
Ambulatory Surgical Center (ASC)
State Licensed Medicare-certified supplier (not provider) of surgical healthcare services that must accept assignment on Medicare Claims.
Ambulatory Surgical Center Payment Rate
Predetermined amount for which ASC services are reimbursed, at 80 percent after adjument for regional wage variations.
Amendment to the HMO Act of 1973
Legislation that allowed federally qualified HMOs to permit members to occasionally use non HMO physicians and be partially reimbursed.
American Academy of Processional Coders (AAPC)
Professional association established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to network, and to increase and promote national recognition and awareness of professional coding.
American Association of Medical Assistants (AAMA)
Enables medical assisting professionals to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients; as well as protect medical assistants’ right to practice.
Claims validation table (as in ANSI ASC X12 837)
American Association of Medical Assistants
Advance Beneficiary Notice
Americans with Disabilties Act
American Hospital Association
American Hospital Formulary Service
American Health Information Management Association
American Medical Association
American National Standards Institute
Ambulatory Payment Classification
All Patient Diagnosis-Related Group
All Patient Refined Diagnosis-Related Group
Accredited Standards Committee
Ambulatory Surgical Center
Beneficary Counseling and Assistance Coordinator
Blue Cross Blue Shield
Blue Cross Blue Shield Association
Beneficiary Services Representative
Cancer or Carcinoma
Common Access Card
Computer Assisted Coding
Computerized Axial Tomography
Certified Coding Specialist
Clinical Data Abstracting Center
Consumer Directed Health Plan
California Department of Health Services
Current Dental Terminology
Comprehensive Error Rate Testing
Civilian Health and Medical Program of Veterans Affairs
Clinical Laboratory Improvement Act
Competitive Medical Plan
Centers of Medicare and Medicaid Services
UB-04 Claim used by institutional and other selected providers to bill payers
Insurance claim used by noninstitutional providers and supplier to bill payers
clinical nurse specialist
Coordination of Benefits
Consolidated Omnibus Budget Reconciliation Act of 1985
Ceterifed Professional Coder
Current Procedural Terminology
CHAMPUS Reform Initative
Customized Sub-Capitation Plan
Debt Collection Assistance Officer
Defense Enrollment Eligibility Reporting System
Durable Medical Equipment
Durable Medical Equipment, Prosthetic and Orthotic Supplies
Durable Medical Equipment regional carriers
Department of Defense
Diagnosis related groups
Disproportionate share hospital (adjustment)
Diagnostic and statistical manual
(California) Employment Development Department
Electronic data interchange
Electronic funds transfer
Employer group health plan
Electronic Healthcare Network Accreditation Commission
Electronic Health Record
Evaluation and Management
Electronic Media Claim
Electronic Medical Record
Explanation of Benefits
Exclusive provider organization
Early and Periodic screening, diagnostic, and treatment
External Quality Review Organization
Electronic Remittance Advice
Employee Retirements income security Act of 1974
First Look Analysis for Hospital Outlier Monitoring
False Claims Act
Fair Debt Collection Practices Act
Federal Employment Compensation Act
Federal Employee Health Benefit Program
Federal Employment Liability Act
Federal Employee Program
Federal Medical Assistance Percentage
Federal Proverty Level
Flexible Spending Account
General Equivalency Mapping
General Enrollment Period
Geographic Cost Practice Index
Group Practice Without Walls
Home Assessment Validation and Entry
Healthcare Common Procedure Coding System
Healthcare reimbursement Account
Health Plan Employer Data and Information Set
Home Health Resource Group
Healh Insurance claim number
Health Insurance portability and accountability Act of 1996
Health insurance prospective payment system (code set)
Health Maintenance Organization
Hospital Payment Monitoring Program
Health personnel shortage area
Health reimbursement arrangement
Health Savings account
Health savings security account
lack of, down
out, away from
instrument for reading
process of recording
gyn-, gyne-, gynec-
ileum (small intestine)
ilium (hip bone)
in, into, not
beneficiary counseling and assistance coordinator (BCAC)
individual available at military treatment facility (MTF) to answer questions, help solve healthcare related problems, and assist beneficiaries in obtaining medical care through TRICARE; was previously called health benefits advisor (HBA)
benefit period (Medicare)
begins with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days.
the legal business name of the provider’s pratice.
determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.
black box edits
nonpublished code edits, which were discontinued in 2000.
program that allows BCBS subscribers to receive local Blue Plan healthcare benefits while traveling or living outside of their plan’s area.
Blue Cross (BC)
insurance plan created in 1929 when Baylor University Hospital, in Dallas, TX, approached teachers in Dallas school district with a plan that guaranteed up to 21 days of hospitalization per year for subscribers and each dependent for a $6 annual premium.
Blue Cross Blue Shield (BCBS)
joint venture between Blue Cross and Blue Shield where the corporation shared one building and computer
The coding system currently in use to report diagnoses and reasons for encounter is the:
International Classification of Diseases, 9th revision, clinical modification (ICD-9-CM)
The person who prepares and reviews claims for accuracy to ensure prompt payment is the :
Health Insurance Specialist
Medical Ethics are:
Principles of right or good conduct
A person who performs services for another under an expressed or implied agreement is called a(n):
Which is an authorization that must be received from a payer before treatment by a specialist wil be covered?
Which coding systerm is used to report professional services to payers?
Current Procedural Terminology (CPT)
Which is a crucial skill that all health insurance specialists should learn in their training coursework?
Fluency in the language of medicine
Which is a professional member of the healthcare team who provides servies or supplies to the insured?
Which is the universal claim form used by physicians offices?
Centers of Medicare and Medicaid Services-150 (CMS-1500)
Which document is mailed by the payer to the patient to illustrate the reimbrsement amount of a covered benefit?
Explanation of Benefits
Which term means the patient is not responsible for paying for what the insurance plan denies?
Hold Harmless Clause
Which document communicates to the payer that the provider is requesting reimbursement?
Health Insurance Claim
Which professional association was founded to eleate the standards of medical coding by providing certification, ongoing education, networking, and recognition for coders?
American Academy of Professional Coders (AAPC)
Which professioinal association was founded to improve the quality of medical records and current advances toward an electronic and global environment including the implementation of ICD-10-CM
American Health Information Managment Association (AHIMA)
Which is a legal term that indicates that providers responsibility for their employees actions and omissions
Blue Cross Blue Shield (BCBS)
joint venture between Blue Cross and Blue shield where the corporations shared one building and computer services but maintained seperate corporate identities.
Blue Cross Blue Shield Association (BCBSA)
an association of independent Blue Cross Blue Shield plans
Blue Shield (BS)
began as a resolution passed by the house of Delegates at an american Medical Association meetings in 1938; incorporates a concept of voluntary health insurance that encpurages physicians to corporate with prepaid health plans.
Blue Worldwide Expat
provides global medical coverage for active employees and their dependents who spend more than six months outside the United States for six months or more is eligible for Blue World Expat.
an insurance agreement that guarantees repayment for financial losses resulting form the act or failure to act of an employee. It protects the financial operations of the employer.
breach of confidentiality
unauthorized release of patient information to third party.
business liability insurance
protect business assets and covers the cost of lawsuits resulting from bodily injury, and false advertising.
also called triple option plan; provides different health benefits palns and extra coverage options through an insure or third-party administrator
provider accepts preestablished payments for providing healthcare services to enrollees over a period of time (usually one year).
carcinoma (Ca) in stiu
in stiu a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs).
care plan oversight services
cover the physician’s time supervising a complex and multidisciplinary care treatment program for specific patient who is under the care of a home health agency, hospice, or nursing facility.
also common law; based on a court decision that establishes a precedent.
development of patient care plans to coordinate and provide care for complicated cases in a cost effective manner.
case mangement services process by which an attending physician coordinates and supervises care provided to patient by other providers.
process by which an attending physician coordinates and supervises care provided to patient by other providers.
submits written confirmation, authorizing treatment, to provider.
the types and categories of patients treated by a healthcare provider.
catastropic cap benefit
protects TRICARE beneficiaries form devastating financial loss due to serious illness or long-term treatment by establisihing limits over which payments is not required
the region defined by code boundaries within a 40-mile radius of a military treatment facility.
Category I Codes
procedures/ services identified by a five- digit CPT code and descriptor nomnclature; these codes are traditionally associated with CPT and orginzed within six sections.
Category II codes
optional performance measurement tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e,g.,1234A); these codes will be located after the medicine section; their use is optional.
Category III codes
temporary codes for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0001T) these codes are located after the Medicine section, and will be archived after five years unless accepted for placement within Category I sections of CPT.