question

accept assignments

answer

Provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and /or coinsurance amounts

question

accounts receivable

answer

the amount owed to a business for services or goods provided

question

allowed charges

answer

the maximum amount the payer will reimburse for each procedure or service, according to the patient's policy

question

appeal

answer

documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment

question

accept assignments

answer

Provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and /or coinsurance amounts

question

allowed charges

answer

the maximum amount the payer will reimburse for each procedure or service, according to the patient's policy

question

appeal

answer

documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment

question

assignment of benefits

answer

the provider receives reimbursement directly from the payer

question

claims adjudication

answer

comparing a claim to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures performed or service

question

claims processing

answer

sorting claims upon submission to collect and verify information about the patient and provider

question

CLaims submission

answer

the transmission of claims data (electronically or manually) to payers or clearinghouses for processing

question

clean claim

answer

a correctly completed standardized claim

question

clearinghouse

answer

performs centralized claims processing for providers and health plans. Facilitates the processing of non-standard data elements into standard data elements

question

coinsurance

answer

also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid

question

common data file

answer

abstract of all recent claims filed on each patient

question

coordination of benefits (COB)

answer

provision in group health insurance policies that prevents multiple insurers from paying benefits covered by other polcies; also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim

question

day sheet

answer

also called manual daily accounts receivable journal; chronologically summary of all transactions posted to individual patient ledgers/accounts on a specific day

question

deductible

answer

amount for which the patient is financially responsible an insurance policy provides coverage

question

ERA electronic remittance advise

answer

remittance advice that is submitted to the provider electronically and contains the same information as a paper-based remittance advice; providers receive the ERA more quickly

question

encounter form

answer

financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter

question

guarantor

answer

person responsible for paying health care fees

question

participating provider (PAR)

answer

contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed

question

patient ledger

answer

also called patient account record; a computerized permanent record of all financial transactions between the patient and the practice

question

preexisting condition

answer

any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollees effective date of coverage

question

superbill

answer

term used for an encounter form in the physician's office

question

unbundling

answer

submitting multiple CPT codes when one code should be submitted

question

assignment of benefits

answer

means that the patient and/or insured has authorized the payer to reimburse the provider directly.

question

Medicare Summary Notice

answer

Providers who do not accept assignment of Medicare benefits do not receive information included on the_____, which is sent to the patient.

question

submission

answer

The transmission of claims data to payers or clearinghouses is called claims:

question

clearinghouse

answer

facilitates processing of nonstandard claims data elements into standard data elements

question

flat file format

answer

A series of fixed-length records submitted to payers to bill for health care services is an electronic flat file format

question

private sector payers that process electronic claims

answer

considered a covered entity

question

open claim

answer

An electronic claim that is rejected because of an error or omission

question

magnetic tape

answer

would be used to transmit electronic claims

question

claims attachment

answer

supporting documentation is associated with submission of an insurance claim

question

coordination of benefits

answer

a group health insurance policy provision that prevents multiple payers from reimbursing benefits covered by other policies

question

processing

answer

The sorting of claims by clearinghouses and payers

question

claims adjudication

answer

Comparing the claim to payer edits andthe patient's health plan benefits

question

noncovered benefit

answer

describes any procedures or service reported on a claim that is not included on the payer's master benefit list

question

common data file

answer

an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider

question

copayment

answer

fixed amont patients pay each time they receive health care services

question

participating provider must accept

answer

whatever a payer reimburses for procedures or services performed

question

Birthday rule

answer

the parent whose birth month and day occurs earlier in the calender year is the primary policyholder

question

chargemaster

answer

the financial record source document usually generated by a hospital

question

truth in lending act

answer

requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions

question

fair credit reporting act

answer

protects information collected by consumer reported agencies

question

verify health identification information on all patients

answer

is the best way to prevent deliquent claims

question

operative report

answer

is an example of suporting documentation

question

special report

answer

term the CPT manual use to refer to supporting documentation

question

clean claim

answer

claim status assigned by the payer to allow the provider to correct errors or omissions on the claim and resubmit for payment consideration

question

HIPAA's national standards for electronic transactions

answer

The intent of mandating HIPAA's national standards for electronic transactions was to improve the efficiency and effectiveness of the health care system

question

Electronic claims

answer

more accurate because they are checked for accuracy by billing software programs or a health care clearinghouse

question

Patients can be billed for

answer

noncovered procedures

question

Medicare calls the remittance advice

answer

provider remittance notice

question

policyholder

answer

The person in whose name the insurance policy is issued

question

The life cycle of an insurance claim is initiated when

answer

the health insurance specialist completes the CMS-1500 claim

question

superbill or encounter form

answer

considered a financial source document

question

fair debt collection practices act

answer

federal law protects consumers against harassing or threatening phone calls from collectors

question

value-added network

answer

clearinghouse that coordinates with other entities to provide additional services during the processing of claims

question

Bonding Insurance

answer

An insurance agreement that guarentees repayment for financial losses resulting from an employee's act or failure to act. Protects employers financial operations.

question

Centers for Medicare and Medicaid Services

answer

The administrative agency within the federal department of health and human services.

question

Current Procedural Terminology (CPT)

answer

Published by the AMA and includes 5 digit numeric and alphanumeric codes and descriptions for procedures and services

question

Electronic Data Interchange (EDI)

answer

Mutual exchange of data between the provider and insurance company

question

Errors and Omissions Insurance

answer

Provides protection from claims that contain errors and omissions resulting from professional services provided to clients (also called professional liability insurance)

question

Ethics

answer

The principles of right and or good conduct

question

Explanation of benefits

answer

A report detailing the results of processing a claim

question

HCPCS Level II Codes (aka-National Codes)

answer

Published by CMS, and include 5 digit numeric and alphanumeric codes for procedures, services,and supplies not classified in CPT

question

Healthcare Common Procedure Coding System

answer

Consists of two levels: Current Procedural Terminology, and National Codes (or HCPCS Level II codes)

question

Hold Harmless Clause

answer

The healthcare provider cannot collect the fees from the patient

question

Independent Contractor

answer

A person who performs services for another under an express or implied agreement and who is not subject to the other's control, or right to control.

question

Medical Necessity

answer

Linking every procedure or service code reported on the claim to an ICD-9 condition code t hat justifies the necessity for performing that procedure or service

question

Preauthorization

answer

Prior approval for treatment

question

Professional Liability Insurance

answer

Protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising

question

Remittance Advice

answer

A notice sent by the insurance company that contains payment information about a claim

question

Health Insurance Claim

answer

The documentation submitted to the payer requesting reimbursement

question

Health Care Financing Administration

answer

The Centers for Medicare and Medicaid Services (CMS) was previously called the

question

Provider

answer

A health care practitioner is also called a...

question

Electronic Data Interchange

answer

The mutual exchange of data between provider and payer

question

Coding

answer

The process of assigning diagnoses, procedures, and services using numeric and alphanumeric characters

question

Payment of the Claim is denied

answer

If the health plan preauthorization requirements are not met by providers,..

question

ICD

answer

coding system is used to report diagnosis and conditions on claims

question

AMA

answer

The CPT coding system is published by

question

HCPCS

answer

National codes are associated with

question

Explanation of Benefits

answer

report sent to the patient to detail the results of claims processing

question

A remittance advice contains

answer

Payment information about a claim

question

Which type of insurance guarantees repayment of financial loss resulting from an employee's act or failure to act?

answer

Bonding

question

Medical malpractice insurance is a type of what insurance?

answer

Liability

question

Who mandates workers' compensation insurance to cover employees and their dependent against injury and death occurring during the course of employment?

answer

state

question

The American Medical Billing Association offers which certification exam?

answer

CMRS

question

The concept that every procedure or service reported to a third-party payer must be linked to a condition that justifies that procedure or service is called?

answer

Medical Necessity

question

The administrative agency responsible for establishing rules for Medicare claims processing is called the.....

answer

Centers for Medicare and Medicaid Services

question

Documentation submitted to an insurance company requesting reimbursement for health care services provided is called a....

answer

Health Insurance Claim

question

Which organization is responsible for administering the Certified Healthcare Reimbursement Specialist certification exam?

answer

AMBA

question

Which clause is implemented if the requirements associated with preauthorization of a claim prior to payment are not met?

answer

Hold Harmless Clause

question

Data published in the Occupational Outlook Handbook indicates the job opportunities for health insurance specialists will increase by what percentage?

answer

9-17 percent

question

The process of reporting diagnoses, procedures and services as numeric and alphanumeric characters on an insurance claim is....

answer

Coding

question

Which is another title for the health insurance specialist?

answer

Claims Examiner

question

Which type of insurance should be purchased by health insurance specialist independent contractors?

answer

Medical Malpractice

question

A health insurance specialist who is able to demonstrate cometency in facilitating the claims reimbursement process from the time a service is rendered by a provider until the balance is paid can qualify for which certification?

answer

Certified Medical Reimbursement Specialist (CMRS)

question

Which certification fulfills the need for an entry-level coding credential?

answer

Certified Coding Assistant (CCA)

question

The intent of managed health care was to

answer

replace fee-for-service plans with affordable, quality care to consumers

question

Which term best describes those who receive managed health care plan services...

answer

enrollees

question

What was created in 1929?

answer

the first managed care program

question

Which was the first nationally recognized health maintenance organization?

answer

Kaiser Permanente

question

During the 1960's debates on how to improve the health care delivery system ensued because:

answer

health care costs had dramatically increased

question

Which legislative provision of TEFRA allows federally qualified HMOs to provide covered services under a rish contract?

answer

medicare risk programs

question

The medical center received a $100,000 capitation payment in January to cover the health care costs of 150 managed care enrollees. By the following January, $80,000had been expanded to cover services provided. The remaining $20,000 is:

answer

retained by the Medical Center as profit

question

Which is a nonprofit organization that contracts with and acquires the clinical and business assets of physician practices?

answer

medical foundation

question

Which is responsible for supervising and coordinating health care services for enrollees?

answer

primary care provider

question

Which term describes requirements created by accreditation organizations?

answer

standards

question

A voluntary process that a health care facility or organization undergoes to demonstrate that is has met standards beyond those required by law -

answer

accreditation

question

Provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year)

answer

capitation

question

Submits written confirmations, authorizing treatment, to the provider

answer

case manager

question

A review for medical necessity of tests and procedures ordered during an inpatient hospitalization

answer

concurrent review

question

Include many choices that provide individuals with an incentive to control the costs of health benefits and health care

answer

consumer-directed health plans (CDHPs)

question

also called \"covered lives\"; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans

answer

enrollees

question

A managed care plan that provides benefits to subscribers if they receive services from network providers

answer

exclusive provider organization (EPO)

question

Reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services.

answer

fee-for-service

question

Primary care provider for essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists

answer

gatekeeper

question

Participants enroll in a relatively inexpensive high-deductible insurance plan, a tax deductible savings account is opened to cover current and future medical expenses. Money deposited is tax-deferred. Unused balances \"roll-over\" from year to year.

answer

health savings account (HSA)

question

Contracted health care services are provided to subscribers by two or more physician multi-specialty group practices

answer

network model HMO

question

A physician or health care facility under contract to the managed care plan.

answer

network provider

question

Include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services

answer

physcian incentives

question

Plan in which patients have freedom to use the HMO panal of providers or to self-refer to non-HMO providers.

answer

point-of-service plans (POS)

question

A network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee

answer

preferred provider organization (PPO)

question

Is responsible for supervising and coordinating health care services for enrollees and approves referrals to specialists and inpatient hospital admissions

answer

primary care providers

question

Reviewing appropriateness and necessity of care provided to patients prior to administration of care

answer

prospective review

question

Reviewing appropriateness and necessity of care provided to patients after the administration of care

answer

retrospective review

question

Method of controlling health care costs and quality of care by reviewing the appropriateness and necessithy of care provided to patients prior to the administration of care

answer

utilization management (utilization review)

question

Employees and dependents who join a managed care plan are called:

answer

enrollees

question

Which act of legislation permitted large employers to self-insure employee healthcare benefits

answer

ERISA

question

If a physician provides services that cost less than the managed care capitation amount, the physician will:

answer

make a profit

question

The primary care provider is responsible for:

answer

supervising and coordinating health care services for enrollees

question

Which is the method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients?

answer

utilization management

question

Accreditation is a _________ process that a healthcare facility can undergo to show that standards are being met:

answer

voluntary

question

Which type of health care plan funds health care expenses by insurance coverage and allows the individual to select one of each type of provider to create a personalized network?

answer

customized sub-capitation plan

question

Which type of consumer-directed health plan carries the stipulation that any funds unused will be lost

answer

health care reimbursement account

question

Which is assessed by the National Committee for Quality Assurance?

answer

managed care plans

question

A case manager is responsible for:

answer

oversee the health services provided to enrollees

question

The event directly responsible for the dramatic increase in U.S. health care costs was the:

answer

implementation of Medicare and Medicaid

question

Which act of legislation provided states with the flexibility to establish HMOs for Medicare and Medicaid programs?

answer

OBRA

question

Which would likely be subject to a managed care plan quality review?

answer

results of patient satisfaction surveys

question

The Quality Improvement System for Managed Care (QISMC) was established by:

answer

Medicare

question

Arranging for a patient's transfer to a rehabilitation facility is an example of:

answer

discharge planning

question

Administrative services performed on behalf of a self-insured managed care company can be outsourced to a :

answer

third party administrator

question

Before a patient schedules elective surgery, many managed care plans require a:

answer

second surgical opinion

question

A \"health delivery network\" is another name for an:

answer

integrated delivery system (IDS)

question

When each provider is paid a fixed amount per month to provide only the care that an individual needs fro that provider

answer

sub-capitation payment

question

A review for medical necessity of inpatient care prior to the patient's admission

answer

preadmission certification

question

This prevents providers from discussing all treatment options with patient's, whether or not the plan would provide reimbursement for service

answer

gag clause

question

This program includes activities that assess the quality of care provided in a helath care setting

answer

quality assurance program

question

This contains data regarding a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control

answer

report card

question

Offered by a single insurance plan or as a joint venture among two or more insurance carriers, provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans

answer

triple option plan

question

Cafeteria plan is also referred to as:

answer

flexible benefit plan

question

which was the first commercial insurance company in the United states to provide private healcare coverage for injuries not resulting in death?

answer

Franklin Health Assurance Company

question

which replaced the 1908 work's compendsation legislation and provideed civilian employees of the fedreal government with medical care, survivors' benefits, and compensation for lost wages?

answer

Federal Employee's Compensation Act

question

the first blue cross policy was introduced by?

answer

Baylor University in Dallas TX

question

the blue sheild concept grew out of the lumber and mining camps of the___ region at the turn of the centurty.

answer

Pacific Northwest

question

Healthcare coverage offered by ____ is called group health insurance.

answer

Employers

question

The Hill-Burton Act provided federal grants for modrenizing hospitals that had become obsolete because of lack of capital investment during the great depression and WW2. In return for fedreal funds, facilities were required to

answer

provide services free or at reduced rates to patients unable to pay for care.

question

Third-party administrators (TPA) administer healthcare plans and process claims, serving as a system of

answer

checks and balances for labor and management

question

Major medical insurance provides coverage for ______ illnesses and injuries, incorporating large deductibles and lifetime maximum amounts.

answer

catastrophic or prolonged

question

The government health plan that provides health care services to Americans over the age of 65 is called

answer

Medicare

question

The Tax Equity and Fiscal Responsibilty Act of 1982 (TEFRA) enacted the _____ prospective pay system (PPS)

answer

Diagnosis-Related Groups (DRGs)

question

The Clinical Laboratory Improvement Act (CLIA) established quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results___

answer

regardless of where the test was performed

question

the ncci promotes national correct coding methodologies and eliminates improper coding. NCCI edits are devloped based on coding conventions defined in ____, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practice.

answer

CPT

question

Utilization and quality control review of healthcare furnished, or to be furnished, to Medicare beneficiaries is currntly performed by ____

answer

quality improvment organizations

question

Which is the primary purpose of the patient record?ensure

answer

continuity of care

question

The Problem-oriented record (POR) includes the following four components

answer

database, problem list, initial plan, progress notes

question

The electronic health record (EHR) allows patient information to be created at different locations according to a unique patient identifier or identification number, which is called

answer

record linkage

question

When a patient states, \"I haven't been able to sleep for weeks,\" the provider who uses the SOAP format documents that statement in the _____portion of the clinic note.

answer

subjective

question

The provider who uses the SOAP format documents the physical examination in the ____ portion of the clinic note.

answer

objective

Understanding Health Insurance 1-4

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards