question

accounting cycle

answer

the flow of financial transactions in a business

question

accounts receivable (AR)

answer

monies that are flowing into a business

question

adjudication

answer

series of steps that determine whether a claim should be paid

question

capitation

answer

payment to a provider that covers each plan member's health care services for a certain period of time

question

coding

answer

the process of translating a description of a diagnosis or procedure into a standardized code

question

coinsurance

answer

percentage of charges that an insured person must pay for health care services after payment of the deductible amount

question

consumer-driven health plan (CDHP)

answer

a type of managed care in which a high-deductible, low-premium insurance plan is combined with a pretax savings account to cover out-of-pocket medical expenses

question

copayment

answer

A fixed fee paid by the patient at the time of an office visit

question

deductible

answer

amount due before benefits start

question

diagnosis

answer

physician's opinion of the nature of the patient's illness or injury

question

diagnosis code

answer

a standardized value that represents a patient's illness, signs, and symptoms

question

documentation

answer

a record of health care encounters between the physician and the patient, created by the provider

question

electronic health record (EHR)

answer

a computerized lifelong health care record for an individual that incorporates data from providers who treat the individual

question

encounter form

answer

a list of the procedures and charges for a patient's visit

question

explanation of benefits (EOB)

answer

document from a payer that shows how the amount of a benefit was determined

question

fee-for-service

answer

health plan that repays the policyholder for covered medical expenses

question

health maintenance organization (HMO)

answer

a managed health care system in which providers agree to offer health care to the organization's members for fixed payments

question

health plan

answer

a plan, program, or organization that provides health benefits

question

managed care

answer

a type of insurance in which the carrier is responsible for both the financing and the delivery of health care

question

medical coder

answer

a person who analyzes and codes patient diagnoses, procedures, and symptoms

question

medical necessity

answer

treatment provided by a physician to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, or its symptoms in a manner that is appropriate and is provided in accordance with generally accepted standards of medical practice

question

medical record

answer

a chronological record of a patient's medical history and care that includes information that the patient provides, as well as the physician's assessment, diagnosis, and treatment plan

question

modifier

answer

a two-digit character that is appended to a CPT code to report special circumstances involved with a procedure or service

question

patient information form

answer

a form that includes a patient's personal, employment, and insurance data needed to complete an insurance claim

question

payer

answer

private or government organization that insures or pays for health care on behalf of beneficiaries

question

policyholder

answer

a software program that automates many of the administrative and financial tasks in a medical practice

question

practice management program (PMP)

answer

a software program that automates many of the administrative and financial tasks in a medical practice

question

preferred provider organization (PPO)

answer

managed care network of health care providers who agree to perform services for plan members at discounted fees

question

premium

answer

the periodic amount of money the insured pays to a health plan for insurance coverage

question

procedure

answer

medical treatment provided by a physician or other health care provider

question

procedure code

answer

a code that identifies a medical service

question

remittance advice (RA)

answer

an explanation of benefits transmitted by a payer to a provider

question

statement

answer

a list of all services performed for a patient, along with the charges for each service

question

administrative safeguards

answer

administrative policies and procedures designed to protect electronic health information outlined by the HIPAA Security Rule

question

audit/edit report

answer

a report from a clearinghouse that lists errors to be corrected before a claim can be submitted to the payer

question

audit trail

answer

a report that traces who has accessed electronic information, when information was accessed, and whether any information was changed

question

autoposting

answer

an automated process for entering information from a remittance advice (RA) into a practice management program

question

breach

answer

the acquisition, access, use, or disclosure of unsecured PHI in a manner not permitted under the HIPAA Privacy Rule

question

clearinghouse

answer

a company that receives claims from a provider, prepares them for processing, and transmits them to the payers in HIPAA-compliant format

question

CMS-1500 (08/05)

answer

the mandated paper insurance claim form

question

computer-assisted coding

answer

assigning preliminary diagnosis and procedure codes using computer software

question

electronic data interchange (EDI)

answer

the exchange of routine business transactions from one computer to another using publicly available communications protocols

question

electronic funds transfer (EFT)

answer

the electronic routing of funds between banks

question

electronic medical records (EMRs)

answer

the computerized records of one physician's encounters with a patient over time

question

electronic prescribing

answer

the use of computers and handheld devices to transmit prescriptions in digital format

question

evidence-based medicine

answer

medical care based on the latest and most accurate clinical research

question

health information technology (HIT)

answer

technology that is used to record, store, and manage patient health care information

question

Health Information Technology for Economic and Clinical Health Act (HITECH)

answer

part of the American Recovery and Reinvestment Act of 2009 that provides financial incentives to physicians and hospitals to adopt EHRs and strengthens HIPAA privacy and security regulations

question

HIPAA (Health Insurance Portability and Accountability Act of 1996)

answer

federal act that set forth guidelines for standardizing the electronic data interchange of administrative and financial transactions, exposing fraud and abuse in government programs, and protecting the security and privacy of health information

question

HIPAA Electronic Transaction and Code Sets standards

answer

regulations requiring electronic transactions such as claim transmission to use standardized formats

question

HIPAA Privacy Rule

answer

regulations for protecting individually identifiable information about a patient's health and payment for health care that is created or received by a health care provider

question

HIPAA Security Rule

answer

regulations outlining the minimum administrative, technical, and physical safeguards required to prevent unauthorized access to protected health care information

question

National Provider Identifier (NPI)

answer

a standard identifier for health care providers consisting of ten numbers

question

personal health records (PHRs)

answer

private, secure electronic files that are created, maintained, and owned by the patient

question

physical safeguards

answer

mechanisms required to protect electronic systems, equipment, and data from threats, environmental hazards, and unauthorized intrusion

question

protected health information (PHI)

answer

information about a patient's health or payment for health care that can be used to identify the person

question

technical safeguards

answer

automated processes used to protect data and control access to data

question

walkout statement

answer

a document listing charges and payments that is given to a patient after an office visit

question

workflow

answer

a set of activities designed to produce a specific outcome

question

X12-837 Health Care Claim (837P)

answer

HIPAA standard format for electronic transmission of a professional claim from a provider to a health plan

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