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Chapter 1
Health Insurance Specialist Career
41
Health Care
Not Applicable
08/21/2010

Additional Health Care Flashcards

 


 

Cards

Term

American Medical Billing Association (AMBA)

Definition

offers the Certified Medical Reimbursement Specialist (CMRS) exam, which recognizes competency of members who have met high standards of proficiency

Term

AMBA

Definition

American Medical Billing Association

Term
American Health Information Management Association (AHIMA)
Definition
professional association that represents more than 40,000 health information management professionals who work throughout the health care industry
Term
AHIMA
Definition
American Health Information Management Association
Term

 American Academy of  Professional Coders (AAPC)

 

Definition
professional association established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to network, and to increase and promote national recognition and awareness of professional coding
Term

bonding insurance

Definition
an insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee. It protects the financial operations of the employer.
Term

Centers for Medicare and Medicaid Services (CMS) 

 

Definition

formerly known as the Health Care Financing Administration (HCFA); an administrative agency within the federal Department of Health and Human Services (DHHS).

Term

Coding

Definition
process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim.
Term

Current Procedural Terminology (CPT)

Definition
published by the American Medical Association; includes five-digit numeric codes and descriptors for procedures and services performed by providers (e.g., 99203 identifies a detailed office visit for a new patient).  
Term
CPT
Definition
Current Procedural Terminology
Term

electronic data interchange (EDI)

Definition
mutual exchange of data between provider and payer.
Term
EDI
Definition
electronic data interchange
Term

electronic claims processing

Definition
sending data in a standardized machine-readable format to an insurance company via disk, telephone, or cable.
Term

embezzle

Definition
the illegal transfer of money or property as a fraudulent action.
Term

explanation of benefits (EOB)

Definition
report that details the results of processing a claim (e.g., prayer reimburses provider $80 on a submitted charge of $100).  
Term
EOB
Definition
explanation of benefits
Term

HCPCS level II

Definition
national codes published by CMS, which include five-digit alphanumeric codes for procedures, services, and supplies not classified in CPT.
Term

Healthcare Common Procedure Coding System (HCPCS)

Definition

coding system that consists of CPT, national codes (level II), and local codes (level III); local codes were discontinued in 2003; previously known as HCFA Common Procedure Coding System.

 

 

 

 

 

 

 

Term

health care provider

Definition
physician or other health care practitioner (e.g., physician's assistant).
Term

health information technician

 

 

Definition

professionals who manage patient health information and medical records, administer computer information systems,and code diagnoses and procedures for health care services provided to patients.

 

Term

health insurance claim

Definition
documentation submitted to an insurance plan requesting reimbursement for health care services provided (e.g., CMS-1500 and UB-04 claims).
Term

health insurance specialist (reimbursement specialist)

Definition
person who reviews health-related claims to determine the medical necessity for procedures or services performed before payment (reimbursement) is made to the provider; see also reimbursement specialists.
Term

hold harmless clause

 

 

Definition
patient is not responsible for paying what the insurance plan denies.
Term

independent contractor

Definition
defined by the 'Lectric Law Library's Lexicon as "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, of the manner and means of performing the services. The organization that hires an independent contractor is not liable for the acts or omissions of the independent contractor."
Term

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Definition
coding system used to report diagnoses (e.g., diseases, signs, and symptoms) and reasons for encounters (e.g., annual physical examination and surgical follow-up care) on physician office claims.
Term
ICD-9-CM
Definition
International Classification of Diseases, 9th Revision, Clinical Modification
Term

liability insurance

Definition
policy that covers losses to a third party caused by the insured, by an object owned by the insured, or on the premises owned by the insured.
Term

medical necessity

Definition
invovles linking every procedure or service reported to the insurance company to a condition that justifies the necessity for performing that procedure or service.
Term

medical malpractice insurance.

Definition
a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment
Term

national codes (level II Codes)

Definition
commonly referred to as HCPCS codes; include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT (e.g., J-codes are used to assign drugs administered).
Term

preauthorization

Definition
prior approval
Term

professional liability insurance (errors and omissions insurance)

Definition

provides protection from claims resulting from errors and omissions associated with professional services provided to clients as expected of a person in their profession; also called errors and omissions insurance.

Term

property insurance

Definition
protects business contents (e.g., buildings and equipment) against fire, theft, and other risks.
Term

remittance advice (remit)

Definition
electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service (from date/thru date), type of bill (TOB), charges, payment information, and reason and/or remark codes.
Term

respondeat superior

Definition
Latin for "let the master answer"; legal doctrine holding that the employer is liable for the actions and omissions of employees performed and committed within the scope of their employment.
Term

scope of practice

 

 

Definition
health care services, determined by the state, that an NP and PA can perform.
Term

workers' compensation insurance

Definition

insurance program mandated by federal and state governments, that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders.

Term
HCPCS
Definition
Healthcare Common Procedure Coding System
Term

ethics

 

 

Definition
principle of right or good conduct; rules that govern the conduct of members of a profession.
Term

CMS

Definition

Centers for Medicare and Medicaid Services

Term

 AAPC

Definition
 American Academy of  Professional Coders
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