Understanding Health Insurance 1-4

Flashcard maker : Henry Smith
accept assignments
Provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and /or coinsurance amounts
accounts receivable
the amount owed to a business for services or goods provided
allowed charges
the maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy
documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment
accept assignments
Provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and /or coinsurance amounts
allowed charges
the maximum amount the payer will reimburse for each procedure or service, according to the patient’s policy
documented as a letter, signed by the provider, explaining why a claim should be reconsidered for payment
assignment of benefits
the provider receives reimbursement directly from the payer
claims adjudication
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
claims processing
sorting claims upon submission to collect and verify information about the patient and provider
CLaims submission
the transmission of claims data (electronically or manually) to payers or clearinghouses for processing
clean claim
a correctly completed standardized claim
performs centralized claims processing for providers and health plans. Facilitates the processing of non-standard data elements into standard data elements
also called coinsurance payment; the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid
common data file
abstract of all recent claims filed on each patient
coordination of benefits (COB)
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
day sheet
also called manual daily accounts receivable journal; chronologically summary of all transactions posted to individual patient ledgers/accounts on a specific day
amount for which the patient is financially responsible an insurance policy provides coverage
ERA electronic remittance advise
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
encounter form
financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter
person responsible for paying health care fees
participating provider (PAR)
contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed
patient ledger
also called patient account record; a computerized permanent record of all financial transactions between the patient and the practice
preexisting condition
any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollees effective date of coverage
term used for an encounter form in the physician’s office
submitting multiple CPT codes when one code should be submitted
assignment of benefits
means that the patient and/or insured has authorized the payer to reimburse the provider directly.
Medicare Summary Notice
Providers who do not accept assignment of Medicare benefits do not receive information included on the_____, which is sent to the patient.
The transmission of claims data to payers or clearinghouses is called claims:
facilitates processing of nonstandard claims data elements into standard data elements
flat file format
A series of fixed-length records submitted to payers to bill for health care services is an electronic flat file format
private sector payers that process electronic claims
considered a covered entity
open claim
An electronic claim that is rejected because of an error or omission
magnetic tape
would be used to transmit electronic claims
claims attachment
supporting documentation is associated with submission of an insurance claim
coordination of benefits
a group health insurance policy provision that prevents multiple payers from reimbursing benefits covered by other policies
The sorting of claims by clearinghouses and payers
claims adjudication
Comparing the claim to payer edits andthe patient’s health plan benefits
noncovered benefit
describes any procedures or service reported on a claim that is not included on the payer’s master benefit list
common data file
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
fixed amont patients pay each time they receive health care services
participating provider must accept
whatever a payer reimburses for procedures or services performed
Birthday rule
the parent whose birth month and day occurs earlier in the calender year is the primary policyholder
the financial record source document usually generated by a hospital
truth in lending act
requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions
fair credit reporting act
protects information collected by consumer reported agencies
verify health identification information on all patients
is the best way to prevent deliquent claims
operative report
is an example of suporting documentation
special report
term the CPT manual use to refer to supporting documentation
clean claim
claim status assigned by the payer to allow the provider to correct errors or omissions on the claim and resubmit for payment consideration
HIPAA’s national standards for electronic transactions
The intent of mandating HIPAA’s national standards for electronic transactions was to improve the efficiency and effectiveness of the health care system
Electronic claims
more accurate because they are checked for accuracy by billing software programs or a health care clearinghouse
Patients can be billed for
noncovered procedures
Medicare calls the remittance advice
provider remittance notice
The person in whose name the insurance policy is issued
The life cycle of an insurance claim is initiated when
the health insurance specialist completes the CMS-1500 claim
superbill or encounter form
considered a financial source document
fair debt collection practices act
federal law protects consumers against harassing or threatening phone calls from collectors
value-added network
clearinghouse that coordinates with other entities to provide additional services during the processing of claims
Bonding Insurance
An insurance agreement that guarentees repayment for financial losses resulting from an employee’s act or failure to act. Protects employers financial operations.
Centers for Medicare and Medicaid Services
The administrative agency within the federal department of health and human services.
Current Procedural Terminology (CPT)
Published by the AMA and includes 5 digit numeric and alphanumeric codes and descriptions for procedures and services
Electronic Data Interchange (EDI)
Mutual exchange of data between the provider and insurance company
Errors and Omissions Insurance
Provides protection from claims that contain errors and omissions resulting from professional services provided to clients (also called professional liability insurance)
The principles of right and or good conduct
Explanation of benefits
A report detailing the results of processing a claim
HCPCS Level II Codes (aka-National Codes)
Published by CMS, and include 5 digit numeric and alphanumeric codes for procedures, services,and supplies not classified in CPT
Healthcare Common Procedure Coding System
Consists of two levels: Current Procedural Terminology, and National Codes (or HCPCS Level II codes)
Hold Harmless Clause
The healthcare provider cannot collect the fees from the patient
Independent Contractor
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.
Medical Necessity
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
Prior approval for treatment
Professional Liability Insurance
Protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising
Remittance Advice
A notice sent by the insurance company that contains payment information about a claim
Health Insurance Claim
The documentation submitted to the payer requesting reimbursement
Health Care Financing Administration
The Centers for Medicare and Medicaid Services (CMS) was previously called the
A health care practitioner is also called a…
Electronic Data Interchange
The mutual exchange of data between provider and payer
The process of assigning diagnoses, procedures, and services using numeric and alphanumeric characters
Payment of the Claim is denied
If the health plan preauthorization requirements are not met by providers,..
coding system is used to report diagnosis and conditions on claims
The CPT coding system is published by
National codes are associated with
Explanation of Benefits
report sent to the patient to detail the results of claims processing
A remittance advice contains
Payment information about a claim
Which type of insurance guarantees repayment of financial loss resulting from an employee’s act or failure to act?
Medical malpractice insurance is a type of what insurance?
Who mandates workers’ compensation insurance to cover employees and their dependent against injury and death occurring during the course of employment?
The American Medical Billing Association offers which certification exam?
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?
Medical Necessity
The administrative agency responsible for establishing rules for Medicare claims processing is called the…..
Centers for Medicare and Medicaid Services
Documentation submitted to an insurance company requesting reimbursement for health care services provided is called a….
Health Insurance Claim
Which organization is responsible for administering the Certified Healthcare Reimbursement Specialist certification exam?
Which clause is implemented if the requirements associated with preauthorization of a claim prior to payment are not met?
Hold Harmless Clause
Data published in the Occupational Outlook Handbook indicates the job opportunities for health insurance specialists will increase by what percentage?
9-17 percent
The process of reporting diagnoses, procedures and services as numeric and alphanumeric characters on an insurance claim is….
Which is another title for the health insurance specialist?
Claims Examiner
Which type of insurance should be purchased by health insurance specialist independent contractors?
Medical Malpractice
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?
Certified Medical Reimbursement Specialist (CMRS)
Which certification fulfills the need for an entry-level coding credential?
Certified Coding Assistant (CCA)
The intent of managed health care was to
replace fee-for-service plans with affordable, quality care to consumers
Which term best describes those who receive managed health care plan services…
What was created in 1929?
the first managed care program
Which was the first nationally recognized health maintenance organization?
Kaiser Permanente
During the 1960’s debates on how to improve the health care delivery system ensued because:
health care costs had dramatically increased
Which legislative provision of TEFRA allows federally qualified HMOs to provide covered services under a rish contract?
medicare risk programs
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:
retained by the Medical Center as profit
Which is a nonprofit organization that contracts with and acquires the clinical and business assets of physician practices?
medical foundation
Which is responsible for supervising and coordinating health care services for enrollees?
primary care provider
Which term describes requirements created by accreditation organizations?
A voluntary process that a health care facility or organization undergoes to demonstrate that is has met standards beyond those required by law –
Provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year)
Submits written confirmations, authorizing treatment, to the provider
case manager
A review for medical necessity of tests and procedures ordered during an inpatient hospitalization
concurrent review
Include many choices that provide individuals with an incentive to control the costs of health benefits and health care
consumer-directed health plans (CDHPs)
also called \”covered lives\”; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans
A managed care plan that provides benefits to subscribers if they receive services from network providers
exclusive provider organization (EPO)
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.
Primary care provider for essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists
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.
health savings account (HSA)
Contracted health care services are provided to subscribers by two or more physician multi-specialty group practices
network model HMO
A physician or health care facility under contract to the managed care plan.
network provider
Include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services
physcian incentives
Plan in which patients have freedom to use the HMO panal of providers or to self-refer to non-HMO providers.
point-of-service plans (POS)
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
preferred provider organization (PPO)
Is responsible for supervising and coordinating health care services for enrollees and approves referrals to specialists and inpatient hospital admissions
primary care providers
Reviewing appropriateness and necessity of care provided to patients prior to administration of care
prospective review
Reviewing appropriateness and necessity of care provided to patients after the administration of care
retrospective review
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
utilization management (utilization review)
Employees and dependents who join a managed care plan are called:
Which act of legislation permitted large employers to self-insure employee healthcare benefits
If a physician provides services that cost less than the managed care capitation amount, the physician will:
make a profit
The primary care provider is responsible for:
supervising and coordinating health care services for enrollees
Which is the method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients?
utilization management
Accreditation is a _________ process that a healthcare facility can undergo to show that standards are being met:
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?
customized sub-capitation plan
Which type of consumer-directed health plan carries the stipulation that any funds unused will be lost
health care reimbursement account
Which is assessed by the National Committee for Quality Assurance?
managed care plans
A case manager is responsible for:
oversee the health services provided to enrollees
The event directly responsible for the dramatic increase in U.S. health care costs was the:
implementation of Medicare and Medicaid
Which act of legislation provided states with the flexibility to establish HMOs for Medicare and Medicaid programs?
Which would likely be subject to a managed care plan quality review?
results of patient satisfaction surveys
The Quality Improvement System for Managed Care (QISMC) was established by:
Arranging for a patient’s transfer to a rehabilitation facility is an example of:
discharge planning
Administrative services performed on behalf of a self-insured managed care company can be outsourced to a :
third party administrator
Before a patient schedules elective surgery, many managed care plans require a:
second surgical opinion
A \”health delivery network\” is another name for an:
integrated delivery system (IDS)
When each provider is paid a fixed amount per month to provide only the care that an individual needs fro that provider
sub-capitation payment
A review for medical necessity of inpatient care prior to the patient’s admission
preadmission certification
This prevents providers from discussing all treatment options with patient’s, whether or not the plan would provide reimbursement for service
gag clause
This program includes activities that assess the quality of care provided in a helath care setting
quality assurance program
This contains data regarding a managed care plan’s quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control
report card
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
triple option plan
Cafeteria plan is also referred to as:
flexible benefit plan
which was the first commercial insurance company in the United states to provide private healcare coverage for injuries not resulting in death?
Franklin Health Assurance Company
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?
Federal Employee’s Compensation Act
the first blue cross policy was introduced by?
Baylor University in Dallas TX
the blue sheild concept grew out of the lumber and mining camps of the___ region at the turn of the centurty.
Pacific Northwest
Healthcare coverage offered by ____ is called group health insurance.
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
provide services free or at reduced rates to patients unable to pay for care.
Third-party administrators (TPA) administer healthcare plans and process claims, serving as a system of
checks and balances for labor and management
Major medical insurance provides coverage for ______ illnesses and injuries, incorporating large deductibles and lifetime maximum amounts.
catastrophic or prolonged
The government health plan that provides health care services to Americans over the age of 65 is called
The Tax Equity and Fiscal Responsibilty Act of 1982 (TEFRA) enacted the _____ prospective pay system (PPS)
Diagnosis-Related Groups (DRGs)
The Clinical Laboratory Improvement Act (CLIA) established quality standards for all laboratory testing to ensure the accuracy, reliability and timeliness of patient test results___
regardless of where the test was performed
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.
Utilization and quality control review of healthcare furnished, or to be furnished, to Medicare beneficiaries is currntly performed by ____
quality improvment organizations
Which is the primary purpose of the patient record?ensure
continuity of care
The Problem-oriented record (POR) includes the following four components
database, problem list, initial plan, progress notes
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
record linkage
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.
The provider who uses the SOAP format documents the physical examination in the ____ portion of the clinic note.

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