Term
| In a managed care delivery system, who is responsible for coordinating all care for the patient? |
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Definition
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Term
Indemnity type insurance has the least amount of structural guidelines for patients to follow
true of false |
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Definition
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Term
Preferred Provider Organizations (PPOs) usually have deductibles and copayment requirements, and the physicians office generally files the claim for services rendered
true or false |
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Definition
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Term
| the two major types of health insurance are |
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Definition
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Term
| _______ plans to integrate the financing and appropriate delivery of services to covered persons by contracting providers for comprehensive health care services, with specific standards for the providers' specialty, and maintaining programs for quality assurance and utilization review |
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Definition
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Term
| Group health insurance generally costs more than individual health insurance and is less comprehensive |
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Definition
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Term
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Definition
| system of medical team members and groups who provide quality and cost-effective care that encompasses both health care delivery and payment for services |
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Term
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Definition
| a joint funding program by federal and state governments (excluding Arizona) for low-income patients on public assistance for their medical care |
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Term
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Definition
| prior authorization for hospital admission and some outpatient and in-office |
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Term
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Definition
| a condition that existed before the insured's policy was issued |
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Term
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Definition
| the geographic are served by an HMO |
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Term
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Definition
| the person who is insired; an insurance policy hoder |
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Term
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Definition
| a printed form containing a list of the services with corresponding codes (encounter form) |
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Term
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Definition
| the charge physicians make to their private patients |
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Term
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Definition
| a review by allied health professionals at predertermined times to assess the necessity of the patient remaining in an acute care facility |
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Term
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Definition
| a government program that provides insurance coverage for people injured on the job or who have developed work-related disorders, disabilities, or illness |
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Term
| the ____ type insurance allows patients to choose their provider and see specialists without referrals |
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Definition
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Term
| any individual may buy health insurance by paying the required ______ |
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Definition
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Term
| if information is given to a third party without the signed authorization of the patient, the one who gave the information may be charged with: |
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Definition
| breach of confidentiality |
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Term
medicaid is health coverage for individuals residing in the USA as illegal aliens
t or f |
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Definition
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Term
| traditional indemnity insurance coverage is often referred to as a(n) _____ plan |
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Definition
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Term
when a couple has children covered by both parents' policies, the Birthday Rule applies: the parent whose birthday falls second in the calendar year is considered the primary carrier
t or f |
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Definition
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Term
the medical assistant should verify the patient's insurance info each time the patient comes in the office
t or f |
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Definition
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Term
| if both usband and wife carry insurance coverage that overlaps, the insured's coverage is considered ______ |
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Definition
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Term
| the primary purpose of HMOs is the containment of health care costs |
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Definition
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Term
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Definition
| authorized signature of the patient for payment to be paid directly to the physician for services |
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Term
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Definition
| established to aid dependents of active service personnel, retired service personnels, and their dependents, and dependents of service personnel who died on active duty, with a sumpplement for medical care in military or public health service facilities |
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Term
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Definition
| Established for the spouses and dependents children of veterans who have total, permanent, service-connected disabilities. |
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Term
| COB coordination of Benefits |
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Definition
| procedures used by insurers to avoid duplication of payment on claims when the patient has more than one policy |
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Term
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Definition
| a specified amount that the insured must pay toward the charge for professional services rendered |
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Term
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Definition
| a predetermined amount that the insured must pay each year before the insurance company will pay for an accident or illness |
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Term
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Definition
| the date when the insurance policy goes into effect |
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Term
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Definition
| a primary care physician who coordinates the patient's hospital admissions, care received from specialists, and so on |
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Term
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Definition
| insurance offered to all employees by the employer |
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Term
| HMO Health Maintenance Organization |
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Definition
| prepaid group practice serving a specific geographic area with a wide range of comprehensive health care at a fixed fee schedule |
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Term
Physicians who treat patients under workers' compensation plans are rquired to register with the state workers' compensation board on an annual basis
t or f |
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Definition
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Term
medical assitatn should verify the patient's ins. info each time the pt. comes in for service
t or f |
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Definition
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Term
which of the following statements about HMO accreditaion is accurate?
a. full accreditation is give for two yrs and indicates excellent performance
b. HMOs that are well equipped to make recommended improvements are give a 10-yrs accreditation
c. provisional accreditaion for 5 yrs is given if the potential for improvement the HMO exist
d. accreditation is denied because the HMO does not meet the national committee for quality assurance standards |
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Definition
| d. accreditation is denied because the HMO does not meet the national committee for quality assurance standards |
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Term
blue cross was originally set up to pay for hospital expenses but now covers outpatient services as well
t or f |
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Definition
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Term
| in managed care delivery system, who is responsible for coordinating all care for the patient |
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Definition
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Term
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Definition
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Term
all physicians by law must be medicaid providers
t or f |
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Definition
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Term
indemnity type insurance has the least amount of structural guidelines for patients to follow
t or f |
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Definition
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Term
a patient cannot be covered by traditional Medicare and a Medicare HMO simultaneously
t or f |
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Definition
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Term
| in which type of HMO are physicians reimbursed on a capitated basis |
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Definition
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Term
| in which type of HMO would you find the physical thrapist, radiologist, and pediatrician all at the same location? |
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Definition
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Term
participating in traditional medicaid does not mean a physician is automatically participating in the a Medicaid HMO plan
t or f |
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Definition
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Term
medicare pays for all routine physicals
t or f |
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Definition
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Term
group health insurance generally costs more than individual health insurance and is less comprehensive
t or f |
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Definition
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Term
many of the large insurance companies publish their provider directories online on the company's website
t or f |
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Definition
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Term
as of October 1, 1995, HIPAA compliance providers were equipped to submit all Medicare claims electronically
t or f |
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Definition
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Term
Medcaid is health coverage for individuals residing in USA as illegal aliens
t or f |
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Definition
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Term
| which type of HMO is composed of individual health care providers joined together to provide prepaid health care to groups and individuals? |
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Definition
| independent practice association |
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Term
current medicare requirements specify that participating physicians must notify all patients of estimated charges
t or f |
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Definition
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Term
| at the time of service, most health maintenance organization HMOs require a copayment of |
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Definition
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Term
preferred provider organizations PPOs usually have deductibles and copayment requirements, and the physician's office generally files the claim for services rendered
t or f |
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Definition
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Term
when a couple has children covered by both parents' policies, the birthday rule applies:
the parent whose birthday is second in the calendar year is considered the primary carrier
t or f |
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Definition
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Term
| which method is best for keeping up to date with medicare changes |
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Definition
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Term
| what is the term used to describe payment by someone else than the patient for services rendered |
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Definition
| third party reimbursement |
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Term
| when a physician agrees to accept the approved amount as his or her fee. this is known as |
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Definition
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Term
| which rule is designated as the main rule of coding |
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Definition
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Term
| CPT codes contain how many digits number |
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Definition
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Term
| today, the most common third party reimbursers are |
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Definition
federal and state agencies
insurance companies
and workers' compensation |
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Term
Before, third party reimbursement was easy and simple
t or f |
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Definition
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Term
| which term would be used to identify an incision and drainage procedure |
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Definition
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Term
| some government payers and commercial insurance carriers require the use of the next year's codes as of |
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Definition
| 10-01 of the current year |
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Term
| how often are the coding books published |
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Definition
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Term
| which code are related to medical services as opposed to surgical services |
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Definition
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Term
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Definition
| to pay back or compensate for money spent |
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Term
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Definition
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Term
| third party reimbursement |
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Definition
| indicated payment made by someone else than pt. |
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Term
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Definition
| named particularly; mentioned in detailed |
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Term
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Definition
| to cut the top or end off; to lop, with insurance |
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Term
| what is the main coding rule to remember |
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Definition
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Term
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Definition
| reason for the pt.'s visit should be coded first, and the other issues coded next in order of importance |
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Term
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Definition
| a system of technical or scientific names |
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Term
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Definition
| International classification of Diseases |
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Term
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Definition
| refers to the purpose or reason for doing a test or procedure, an insurance company criteria for reimbursement |
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Term
| to become an accurate coder, three things are necessary |
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Definition
| understanding of A/P, ICD, terminology, |
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Term
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Definition
| a number of things bound together |
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Term
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Definition
| giving a share; helping toward a result |
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Term
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Definition
| to meet unexpectedly, or by chance |
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Term
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Definition
| one who carries, transport, with insurance, its the company who provides the policy |
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Term
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Definition
| listing of allowable charge |
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Term
| the physician's reimbursement is based upon |
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Definition
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Term
| which level of procedure codes apply only to local areas? |
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Definition
| HCPCS codes W0000 to Z9999 |
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Term
| The International Classification of Diseases (ICD) codes describe the procedures and services provided for a patient |
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Definition
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Term
| _____ compensation is a government program that provides insurance coverage to individuals who are injured on the job |
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Definition
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Term
| A(n) ______ condition is an illness, disease, or injury that occurred before the insured's policy was issued |
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Definition
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Term
| a breach of _____ occurs when info is given to third party without the signed authorization of the pt. |
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Definition
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Term
| miguel and maria have a daughter which was born in Jan 1999. Miguel's birthday is in July 1976 and Maria's birthday is in April 1975. According to the birthday rule, whose policy is primary? |
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Definition
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Term
reimbursement is received only for procedures that relate to identified diagnostic codes
t or f |
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Definition
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Term
indemnity insurance gives patients the option of using the provider of their choice
t or f |
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Definition
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Term
on an insurance claim, the SSN of the pt. is used as the certificate number
t or f |
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Definition
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Term
| john martin died while on active military duty. which plan provides medical care for his dependents? |
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Definition
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Term
the truncated international classification of diseases (ICD) coding ruling states that claims must be coded to the highest level of specificity or they will be rejected
t or f |
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Definition
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Term
| a(n) ______ policy is private supplemental insurance that covers the patient's Medicare deductible and co-payment obligations |
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Definition
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Term
| the holder of the insurance policy is called the : |
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Definition
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Term
filing insurance claims electronically shortens the turnaround time of the payment of insurance claims
t or f |
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Definition
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Term
| which step should be taken before submitting a completed insurance claim form? |
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Definition
| determine that you have the patient's signature on a release of information form |
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Term
| which part of Medicare provides benefits covering inpatient hospital and skilled nursing facilities, hospice care, and blood transfusions? |
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Definition
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Term
| Which type of health maintenance organization (HMO) reimburses physicians on a capitation basis? |
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Definition
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Term
The Centers for Medicare and Medicaid Services (CMS) was formerly known as HCPCS
t or f |
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Definition
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Term
| which of the following may be required before a certain procedure can be performed? |
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Definition
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Term
| which statement is accurate regarding a physician who is participating provider with Medicare? |
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Definition
| the participating physician receives payment directly from Medicare |
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Term
| What is the appropriate first step when a claim has neither been paid nor denied within a reasonable time? |
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Definition
| the first step is to follow up promtly by calling the insurance company |
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Term
once insurance coverage has been verified for a new patient, it is not necessary to verify it again
t or f |
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Definition
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Term
| to __________ meant to pay back or compensate for money spent |
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Definition
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Term
| a(n) _______ is a sum of money to be received yearly, wither in a lump sum or by installments |
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Definition
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Term
| a(n)____ is the money paid for coverage under the insurance contract |
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Definition
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Term
| individual health insurance generally costs less than group health insurance and is more comprehensive |
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Definition
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Term
| when coding claims it is important that certain descriptors are used to define the level of E/M services. Which of the following is not one of those components? |
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Definition
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Term
| Patients insured with Medicare part B receive free lab services? |
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Definition
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Term
| Which type of HMO offers its members the greatest flexibility in their choice of health care? |
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Definition
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Term
| the national provider indentification number used when filing Medicare claims is unique to each physician and replaced what prior identification numbers? |
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Definition
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Term
| code books are updated every 5 yrs to ensure correct codes are being used |
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Definition
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Term
| in insurance billing the reason rule states that you must code reason of the patient encounter first |
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Definition
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Term
HMOs allow the pt. the option of using network or nonnetwork physicians and hospitals
t or f |
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Definition
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Term
| most appropriate term used to describe determining not only if services are covered, but if the purpose of the procedure is necessary |
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Definition
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Term
the birthday rule applies only to children of divorced parents
t or f |
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Definition
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Term
| under most managed care plans a pt. will be required to make a copyment of $5.00 to $100.00 per visit depending on the insurance company's policies |
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Definition
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Term
| EOB stands for estimation of benefits |
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Definition
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Term
| what would be an example of a HCPCS for orthotics? |
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Definition
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Term
| what would the HCPCS J cods be for? |
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Definition
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Term
| _______ is when a person is given information about a pt. without a signed authorization |
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Definition
| breach of confidentiality |
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Term
| HCPCS codes are used only in hospital settings |
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Definition
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Term
an insurancxe claim will be denied by an insurance company if an incorrect ICD-9-CM code is used
t or f |
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Definition
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Term
| what is the initial purpose of HMOs? |
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Definition
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Term
| indemnity type insurance has the most structural guidelines of all insurances that patients must follow |
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Definition
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Term
| the physician is required to file Medicare claims for Medicare patients rather than the patients filing their own claims |
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Definition
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Term
| knowingly submitting a false Medicare claim is punishable by incarceration of up to 5 yrs for the person submitting the claim |
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Definition
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Term
| which part of medicare is used for services of a physician in or out of the hospital? |
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Definition
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Term
| Physicians who treat patients under workers' compensation plans have to register with the Workers' Compensation Board every 2 yrs |
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Definition
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Term
| which type of insurance requires a pt. to pay in full at the time aervice is provided |
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Definition
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Term
| which major health insurance plan was originally set up to pay for hospital expenses? |
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Definition
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Term
| the two major types of health insurance are individual and group |
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Definition
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Term
| the largest industry in the USA is insurance |
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Definition
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Term
| a fee schedule is also referred to as an agreed rate for service |
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Definition
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Term
| large insurance companies publish their provider directories on their Web sites |
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Definition
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Term
| When doing manual claims it is important to make a copy of the completed claim forms before you send them to the insurance company |
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Definition
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Term
| only a person whi is 65 yrs old or older can receive medicare |
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Definition
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Term
| HMOs are also referred to as managed care |
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Definition
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