question

private or government organization that insures or pays for health care on behalf of beneficiaries and agrees to carry some of the risk of paying for services

answer

third party payer

question

__________(policyholder) is the first party, and the __________ is the second party

answer

patient, physician

question

most popular type of health plan

answer

PPO

question

they have the most stringent guidelines and the narrowest choice of providers.

answer

HMO

question

HMO members are assigned _________ and must use the network except in emergencies or pay a penalty

answer

PCP

question

organized around one of three business models: the staff model, the group or network model, and the independent practice associate model.

answer

HMO

question

_____________ include the federal employees health benefits program, self insured health plans, individual health plans

answer

private insurance payers

question

whether participating provider can bill the patient for the difference between a higher physician fee and a lower allowed charge

answer

balance billing

question

____________ tab contains basic information such as the plan name, address, and contact information

answer

address

question

detailed information about an insurance carrier is stored in the ________________ for each carrier

answer

insurance carrier dialog box

question

to view information on a carrier already in the database select the carrier in the insurance carrier list dialog box and click the __________ button

answer

edit

question

to enter a carrier not already in the database, click the ______ button

answer

new

question

the ______ tab contains information used for _________ claims and online eligibility verification

answer

EDI/eligibility, electronic

question

tab that list procedure codes in the database and the amounts allowed by the payer for procedures

answer

allowed tab

question

_____ are entered in the allowed tab of the insurance carrier dialog box

answer

values

question

three types of transactions are recorded in the PM/EHR:

answer

charges, payments, adjustments

question

during __________ you must provide a receipt for the patient, schedule follow up appointment, provide referral, and provide patient education materials

answer

check out

question

the national center for health statistics and the centers for medicare and medicaid services (CMS) release ICD-9CM updates called the ___________ twice a year

answer

addenda

question

_______ codes must be used for _________ encounters as of the date they go into effect

answer

current, reporting

question

CPT is a ____________ meaning that it is not available for free to the public. rather, the information must be purchased from the american medical association (AMA) which issues revised __________ each year

answer

proprietary code set, CPT codes

question

annual changes are released by the AMA on ____________ & are in effect for procedures and services provided after ___________ of the following year

answer

october 1, january 1

question

PM/EHRs typically include a software feature known as a __________ this software tool analyzes ___________ for patient encounters and reports those that appear to be outdated or otherwise problematic

answer

claim scrubber, medical codes

question

the PM/EHR must be updated to reflect code changes based on the scrubbers report ___________ the claim is submitted

answer

before

question

medical services provided should be ____________ so that the ____________ of the charges is clear to the health plan

answer

logically connected, medical necessity

question

____________ describes the connection between a procedure code and the related diagnosis code. procedures must be clinically appropriate, & not primarily for the convenience of the patient

answer

code linkage

question

if medical necessity is not met, the __________ will not receive payment from the health plan

answer

physician

question

the procedure/payment/adjustment list dialog box lists codes ______ in the database

answer

already

question

the process of adding _______ procedure codes to the database begins with selecting procedure/payment/adjustment codes on the _________

answer

new, lists menu

question

when the new button is clicked, the procedure/payment/adjustment dialog box is displayed which has three tabs:

answer

general, amounts, allowed amounts

question

the ____________ tab shows the amount charged for the procedure as listed in the practices fee schedule

answer

amounts

question

the __________ tab lists the amount each insurance carrier pays for a particular code

answer

allowed amounts

question

in the allowed amounts tab of the procedure/payment/adjustment (new) dialog box the following columns are listed INSURANCE NAME, __________, ___________, __________

answer

code, modifiers, amount

question

health plans set a __________- a certain length of time in which the expected services are to be provided- for each package.

answer

global period

question

__________ controls improper coding that would lead to inappropriate payment for medicare claims

answer

CCI (correct coding initiative)

question

CCI (correct coding initiative) edits also test for _____________

answer

unbundling

question

CCI (corrrect coding initiative) requires ____________ to report only the more extensive version of the procedure performed and disallows reporting of both extensive and limited procedures

answer

physicians

question

a __________ is related to a specific CPT or HCPCS code and applies to the services that a single provider (or supplier, for supplies such as durable medical equipment) provides for a single patient on the same date of service .

answer

MUEs (medically unlikely edits)

question

ideal tool for collecting at the time of service is known as _______________

answer

RTCA (real time claim adjudication)

question

information transmitted by the health plan in RTCA allows the practice to know the patients __________ for the visit and collect it as well as verify that the services are covered under the policy known as ____________

answer

financial responsibility, eligibility of benefits

question

note that the RTCA does not generate a ___________ payment

answer

real-time

question

claims communicate information about a patients _________, __________, & __________ to a payer

answer

diagnosis, procedures, charges

question

the HIPAA standard transaction for electronic claims is the _________________

answer

HIPAA X12 837 health care claim

question

insurance claims are __________, __________, & __________ for payment within the claim management area of MNP

answer

created, edited, submitted

question

the upper right corner of the claim management dialog box contains five _______________ that simplify the task of moving from one entry to another

answer

navigator buttons

question

the ___________ button makes the last claim in the list active

answer

last claim

question

the bottom of the ________ management dialog box contains a number of buttons that are used for various functions ________ opens a claim for editing

answer

claim, edit

question

the create claims dialog box is accessed by clicking the _________ button in the claim management dialog box. this dialog box provides several filters to customize the ______________

answer

create claims , creation of claims

question

condition that data must meet to be selected

answer

filter

question

filters can be used to create claims for a specific patient & carrier, and for transactions that exceed a ______________

answer

certain dollar amount

question

the __________ is the patients regular physician

answer

assigned provider

question

the transaction tab lists information about the transactions included in a claim such as the ___________, ___________, & ___________

answer

diagnosis, procedure, amount

question

claims that have been created in medisoft network professional (MNP) are submitted using the revenue management to _________________ claims to clearinghouses as well as ___________ to payers via _________

answer

electronically transmit, directly, mail

question

insurance claims are created from within the ______________ area of medisoft network professional

answer

claim management

question

the HIPAA standard transaction for electronic claims is the HIPAA ____________ health care claim

answer

X12 837

question

claims are billed to medicare and then submitted ti medicaid are called _____________

answer

crossover claims

question

medisoft network professionals __________ feature allows claims to be reviewed and edited before they are submitted to insurance carriers for payment

answer

claim edit

practice management & EHR chap. 8-10 – Flashcards

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