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final study guide for hit 296
AMBULATORY DATA SYSTEMS
235
Medical
Undergraduate 4
12/03/2011
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Term
CROSSOVER
 Definition
THE REASSIGNMENT OF THE GAPS IN COVERAGE THAT ELMINATES THE NEED FOR FILING A SEPARATE CLAIM WITH MEDIGAP
Term
OUTLINER
 Definition
A HOSPITAL CASE THAT FALLS BELOW THE MEAN AVERAGE OR EXPECTED LENGTH OF STAY FOR SPECIFIC DRG
Term
GA
 Definition
MODIFIER USED ON A CLAIM FORM TO IDENTIFY THAT A PATENT HAS SIGNED AN (ABN)AND THAT IT IS ON FILE WITH THE PROVIDER
Term
INLINER
 Definition
A HOSPITAL CASE THAT EXCEEDS A SPECIFIC DRG LENGTH OF STAY
Term
MEDICARE SECONDARY PAYER (MSP)
 Definition
TERM USED WHEN MEDICARE IS NOT RESPONSIBLE FOR PAYING A CLAIM FIRST
Term
WHICH OF THE FOLLOWING IS NOT COVERED BY MEDICARE PATRS A AND B
 Definition
A)LONG-TERM CARE B)ROUTINE DENTAL CARE C)ROUTINE EYE CARE D)ALL OF ABOVE. ANSWER D
Term
WHICH OF THE FOLLOWING CONSIDERD MEDICALLY NECESSARY
 Definition
A) AN ELECTIVE PROCEDURE B) AN EXPERIMENTAL OR INVESTIGATIONAL PROCEDURE C) AN ESSENTIAL TREATMENT D) NONE ABOVE: ANSWER C
Term
WHEN DOES A HOSPITAL SUBMIT A BILL FOR ITS SERVICES FOR AN INPATIENT CASE
 Definition
AFTER THE DISCHARGE SUMMARY IS COMPLETED AND SIGNED BY THE PHYSICIAN
Term
WHAT IS THE NAME OF THE FORM THAT MEDICARE PATIENTS MUST SIGN WHEN A CHARGE WILL NOT BE COVERED BY MEDICARE
 Definition
ADVANCED BENEFICIARY NOTICE (ABN)
Term
WHAT IS A DRG CREEP
 Definition
AN UNETHICAL AND UPCODING A PATIENT'S CASE
Term
HOW MANY TIMES A YEAR SHOULD AN INTERNAL REVIEW BE PERFORMED
 Definition
ONE OR TWO TIMES A YEAR
Term
BENEFITS OF HAVING A VOLUNTARY COMPLIANCE PROGRAM ARE
 Definition
REDUCING THE CHANCES OF AN EXTERNAL AUDIT, AVOIDING CONFLICTS W/SELF REFERRAL& ANTI-KICKBACKES STATUES, SPEEDING& OPTIMIZING PROPER PAYMENT OF CLAIMS
Term
WHICH TYPE OF CPT CODES ARE AUDITED THE MOST
 Definition
E/M
Term
WHICH OF THE FOLLOWING IS ATYPE OF LAW THAT CAN PROHIBIT A PHYSICIAN FROM PRACTICING AS A PROVIDER TO GOVERNMENT HEALTH PROGRAMS
 Definition
ADMINISTRATIVE
Term
WHICH OF THE FOLLOWING IS A TYPE OF LAW WHICH REQUIRES THAT AN INDIVIDUAL IS FOIND GUILTY, HE CAN BE SUBJECT TO SERVING JAIL SENTENCE?
 Definition
CRIMINAL
Term
ORGAN SYSTEMS
 Definition
ELEMENTS THAT INCLUDE EYES, EARS,NOSE,THROAT, SKIN,AND PSYCHIATRIC
Term
HPI
 Definition
ELEMENTS THAT INCLUDE TIMING,DURATION,LOCATION,SEVERITY, AND CONTEXT
Term
FEDERAL CIVIL FALSE CLAIMS ACT
 Definition
GOVERNS PHYSICIAN SELF-REFERRAL FOR MEDICARE AND MEDICAID PATIENTS
Term
BODY AREAS
 Definition
ELEMENTS THAT INCLUDE HEAD, CHEST, ABDOMEN,BACK AND GENITALIA
Term
STARK LAW
 Definition
PROHIBITS MAKING FRAUDULENT STATEMENTS OR REPRESENTATION IN CONNECTION WITH A CLAIM AND OUTLINES LIABILITY OF THESE FRAUDULENT ACTS
Term
allied health employee
 Definition
members of the clinical health care professinon who work toether in a healh care team to make the care system function
Term
fraud
 Definition
tobill when a procedure was not done-deception
Term
see also
 Definition
instructions to reference another main term that need to be referenced for other possible useful informatiom
Term
abuse
 Definition
to bill when a procedure is not medical necessary
Term
established patient
 Definition
PERSON WHO HAS BEEN SEEN BY A PHYSCIAN OR PRACTICE WITHIN 3 YEARS
Term
CAPITAION
 Definition
TYPE OF MANAGED CARE CONTRACT PAYMENT WHERE A PROVIDER IS COMPENSATED FOR COVERD SERVICES AT A FIXED MONTHLY PAYMENT (PER MEMEBER PER MONTH AMOUNT)
Term
SEE
 Definition
INSTRUCTIONS TO REFERENCE ANOTHER TERM/CODE BEFORE CHOOSING THE CODE
Term
[ ] BARCKET
 Definition
ENCLOSES SYNONMYMS,ALTERNATIVE WORDING, OR ALTERNATIVE EXPLANATORY PHRASES THAT COULD BE IN THE DIAGNSOTIC STATMENT AND AIDS IN PROPER CODE SELECTION
Term
FEE-FOR SERVICE CONTRACT
 Definition
TYPE OF MANAGED CZRE CONTRACT PAYMENT WHERE COVERED SERVICES ARE COMPENSATED AT A DISCOUNT OF PROVIDER;S USUAL AND COSTOMARY CHARGES
Term
AHIMA (AMEERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION)
 Definition
AWARDS THE CCA, CCS, AND THE RHIT
Term
( ) PARTHENSES
 Definition
ENCLOSES SUPPLEMENTAL WORDS THAT MAY BE PRESENT IN THE DIAGNOSTIC STATMENT, WITHOUT AFFECTING PROPER CODE ASSIGNMENT
Term
NEW PATIENT
 Definition
PERSON WHO HAS NOT BEEN SEEN BY A PHYSICIAN OR PRACTICE FOR THREE YEARS
Term
ADDITIONAL STAFF HAD TO BE ADDED FOR DAILY FINANCIAL OPERATIONS TO BE CARRIED OUT, PAYMENT FOR SERVICES WERE NOT RECEIVED UP FRONT FROM THE PATIENT,MONEY WAS NOT READILY AVAILABLE FOR OPERATIONS
 Definition
ALL HAVE AFFECTED PHYSICIAN OFFICES DUE TO MANAGED CARE
Term
A PERSON WHO IS COVERED UNDER AN INSURANCE POLICY IS KNOWN AS THE?
 Definition
SUBSCRIBER, INSURED, POLICYHOLDER
Term
A PCPs AUTHORIZATION TO ALLOW A PATIENT TO SEE A SPECIALIST FOR MEDICAL CARE REQUIRES WHAT TYPE OF HOM UTILIZATION
 Definition
REFERRAL
Term
A COMBINATION CODE IN ICD-9-CM COVERS THE
 Definition
ETIOLOGY AND MANIFESTATION
Term
WHICH IS NOT TRUE IN RELATION TO ADD ON CODES
 Definition
CAN BE USED AS A STAND ALONE/PRIMARY PROCEDURE CODE
Term
FIVE DIGIT CODE IN ICD-9-CM IS CALLED A
 Definition
SUBCLASSIFICATION
Term
THE PATIENT BILL OF RIGHTS CONSISTS OF THIS PRINCPLE
 Definition
RESPECT AND NONDISCRIMINATION. INFORMATION DISCLOSUR,CONFIDENTIALITY OF HEALTH INFORMATION
Term
THE DRG INDICATES THE MEDICATIONS THE PATIENTS IS TAKING WHILE IN THE HOSPTAL
 Definition
FALSE
Term
hosptials bill for services only after the discharge summary is completed and signed by the physician
 Definition
false
Term
AN OCCURENCE CODE DESCRIBES THE ACCIDENT OR MISHAP RESPONSIBLE FOR THE PATIENT'S ADMISSION
 Definition
TRUE
Term
THE REVENUE CODE IS A FIVE DIGIT CODE NUMBER REPRESENTING A SPECIFIC ACCOMMODATION, ANCILLARY SERVICE, OR BILLING CALCULATION RELATED TO THE SERVICE
 Definition
FALSE
Term
AMBULATORY PAYMENT CLASSIFICATION (APC) SYSTEM IS BASED ON PROCEDURES RATHAN DIAGNOSIS
 Definition
TRUE
Term
AN INPIENT IS ONE WHO HAS BEEN SEEN IN THE EMERGENCY DEPARTMENT
 Definition
FALSE
Term
A CASE THAT CANNOT BE ASSIGNED AN APPROPRIATE DRG BECAUSE OF AN ATYPICAL SITIUATION IS CALLED A BUDGET OUTLINER
 Definition
FALSE
Term
A CASE THAT CANNOT BE ASSIGNED AN APPROPRIATE DRG BECAUSE OF AN ATYPICAL SITIUATION IS CALLED A BUDGET OUTLINER
 Definition
FALSE
Term
THE TYPE OF DISCHARGE STATUS DEFINES WHERE THE PATIENT WAS DISCHARGED TO
 Definition
TRUE
Term
THE RENDERING PROVIDER IS THE PROVIDER WHO ATTENDED THE PATIENT
 Definition
FALSE
Term
THE PNC IS THE UNIQUE NUMBER GIVEN TO THE PATIENT AT ADMISSION
 Definition
TRUE
Term
PATIENT'S REASON FOR VISIT IS REQUIRED ONLY ON SCHEDULED OUTPATIENT VISITS FOR OUTPATIENT BILLS
 Definition
TRUE
Term
BIRTH DATES ON THE UB-04 FORM SHOULD BE SHOWN IN THE MMDDCCYY FORMAT
 Definition
TRUE
Term
THE UB-04 FORM REQUIRES INFORMATION ABOUT THE SOURCE OF A PATIENT'S ADMISSION
 Definition
TRUE
Term
A CHARGE MASTER CONTAINS A HOSPITAL'S LIST OF SERVICES, CODES, ANF CHARGES
 Definition
TRUE
Term
A CHARGE DESCRIPTION MASTER OR CHARGE MASTER INCLUDES
 Definition
PROCEDURE CODES
Term
PRINCIPLE DIAGNOSIS
 Definition
DESCRIBES THE PATIENT'S CONDITION THAT IS THE DIAGNOSIS ESTABLISHED AFTER STUDY OR TESTING
Term
ADMITTING DIAGNOSIS
 Definition
DESCRIBES THE PATIENT'S CONDITION UPON HOSPITAL ADMISSION
Term
PATIENT CONTROL NUMBER
 Definition
UNIQUE NUMBER GIVEN TO THE PATIENT FOR EACH HOSPITAL ADMISSION
Term
CHARGE MASTER
 Definition
SHEET THAT CONTAINS THE FOLLOWING INFORMATION: PROCEDURE CODE, PROCEDURE, DESCRIPTION, SERVICE DESCRIPTION, CHARGE AMD THE REVENUE CODE
Term
AMBULATORY PAYMENT CLASSIFICATION
 Definition
OUTPATIENT PAYMENT CLASSIFICATION SYSTEM BASED ON PROCEDURES
Term
PROSPECTIVE PAYMENT SYSTEM
 Definition
ESTABLISHED PAYMENT RATE FOR HOSPITALS PRIOR TO SERVICES BEING RENDERED
Term
DRG
 Definition
A FORM OF PPS THAT CATERGORIZES DIAGNOSIS AND TREATMENTS INTO GROUPZ
Term
OUTPATIENT PROSPECTIVE PAYMENT SYSTEM
 Definition
OPPS
Term
GROUPER
 Definition
A PROGRAM THAT CALCULATES AND ASSIGNS THE DRG PAYMENT GROUP
Term
COMORBIDITY
 Definition
PREEXISTING CONDITION THAT AFFECTS THE PRINCIPLE DIAGNOSIS
Term
ASU (AMBULATORY SURGICAL UNIT)
 Definition
DEPARTMENT IN THE HOSPITAL THAT PERFORMS OUTPATIENT SERVICES FOR PATIENTS
Term
ASC (AMBULATORY SURGICAL CENTER)
 Definition
DESIGNATED CENTER WHERE OUTPATIENT SERVICES ARE OFFERED TO PATIENTS
Term
PRINCIPLE DIAGNOSIS
 Definition
REASON FOR HOSPITAL STAY
Term
RENDERING PHYSICIAN
 Definition
PROVIDER WHO RENDERS A SERVICE
Term
THE MEDICARE 2007 DEDUCTIBLE FOR PART B IS 200
 Definition
FALSE
Term
AN INTERMEDIARY IS A COMPANY THAT IS PAID TO PROCESS CLAIMS FOR MEDICARE PART A
 Definition
TRUE
Term
THE MEDICAL OFFICE SPECIALIST SHOULD CHECK PATIENTS MEDICARE ELIGIBILITY EACH TIME AN APPOINTMENT IS MADE
 Definition
FALSE
Term
CARE IN SKILLED NURSING IS COVERED UNDER MEDICARE PART B
 Definition
FALSE
Term
THE BENEFIT PEROID MEDICARE PART A IS THE PEROID DURING WHICH A PATIENT IS INSURED
 Definition
TRUE
Term
MEDICARE PART A PROVIDES COVERAGE FOR PHYSCIAN SERVICES AND PROCEDURES
 Definition
FALSE
Term
MEDICARE PART B PROVIDES COVERAGE FOR DURABLE MEDICAL EQUIPMENT
 Definition
TRUE
Term
MEDICARE COVERS AN ANNUAL PHYSICIAL EXAMINATION
 Definition
FALSE
Term
MEDICARE PART B COVERS EYEGLASSES
 Definition
FALSE
Term
FORM LOCATOR 11 ON THE CMS-1500 FORM MUST BE COMPLETED
 Definition
TRUE
Term
INDIVIDUALS WHO ARE OVER 65 WHO DO NOT RECEIVE SOCIAL SECURITY BENEFITS MAY ENROLL IN MEDICARE PART A
 Definition
IF THEY PAY A PREMIUM
Term
UNDER THE MEDICARE PROGRAM, NON PARTICIPATION, NON ACCEPTING ASSIGNMENT PHYSICIAN MAY NOT BILL MORE THAN 115% OF
 Definition
THE MEDICARE LIMITING CHARGE ON THE NON PAR MEDICARE FEE SCHEDULE
Term
WHAT PERCENTAGE OF THE FEE ON THE MEDICARE FEE SCHEDULE IS THE LIMITING CHARGE
 Definition
115%-
Term
UNDER THE MEDICARE PROGRAM, IF THE APPROVED AMOUNT FOR A PROCEDURE IS $100.00, THE PARTICIPATING PROVIDER WILL BE PAID $100.00 (BY MDICARE AND THE PATIENT), AND THE NONPARTICIPATING PROVIDER WHO ACCEPTS ASSIGNMENT WILL BE PAID.
 Definition
$95.00
Term
PEOPLE WHO ARE ENTITLED TO MEDICARE PART A BENEFITS AUTOMATICALLY QUALIFY FOR MEDICARE
 Definition
PART B
Term
WHEN A PATIENT IS OVER 65 AND EMPLOYED, THE EMPLOYER'S GROUP HEALTH PLAN, NOT MEDICARE IS THE
 Definition
PRIMARY PLAN
Term
IF AN INDIVIDUAL IS RECEIVING COVERAGE UNDER A COBRA CASE AS WELL AS MEDICARE, THE MEDICARE PLAN IS THE
 Definition
PRIMARY PAYER
Term
UNDER RULES OF THE MEDICARE PROGRAM, A PATIENT MAY SIGN A
 Definition
lifetime release

lifetime beneficiary claim authorization and information release form
Term
PHYSICIANS WHO PARTICIPATE IN THE MEDICARE PROGRAM CAN BILL PATIENTS FOR SERVICES THAT ARE
 Definition
EXEMPT
Term
MEDICARE C
 Definition
INCLUDES BENEFITS OF MEDICARE PART A AND PART B CLAIMS
Term
THE CMS-FORM IS USED TO
 Definition
FILE MEDICARE PART B CLAIMS
Term
FEE-FOR-SERVICE
 Definition
INSURANCE COVERAGE IS OFFERED UNDER THE ORIGINAL MEDICARE PLAN
Term
THE MEDIGAP PLAN IS
 Definition
SUPPLEMENTAL TO MEDICARE
Term
FOR MEDICARE TO DETERMINE IF THE PATIENT HAS BEEN NOTIFIED IN ADVANCE THAT HE WILL BE RESPONSIBLE FOR PAYMENT, A______MODIFIER IS USED WITH THE PROCEDURE
 Definition
GA MODIFIER
Term
IF THE PATIENT REFUSES TO SIGN THE ABN FOR A NONASSIGNED CLAIM, USE A ______ MODIFIER
 Definition
GZ MODIFIER
Term
DEFINE TRHCA
 Definition
TAX RELIEF AND HEALTHCARE ACT
Term
THE TURNAROUND TIME FOR PAPER CLAIMS IS_______DAYS, AND FOR ELECTRONIC CLAIMS IS______DAYS
 Definition
29 DAYS AND 14 DAYS
Term
CMS HAS STATED THAT THE PLACE OF SERVICE MUST ALSO BE FULLY WRITTEN OUT IN FORM LOCATOR_____.
 Definition
LOCATOR 32
Term
UNDER THE PAYER OF LAST RESORT REGULATION, MEDICAID PAYS LAST ON A CLAIM WHEN A PATIENT HAS OTHER EFFECTIVE INSURANCE COVERAGE
 Definition
TRUE
Term
THE MEDICAL SPECIALIST OFFICE SPECIALIST SHOULD CHECK PATIENTS' MEDICAID ELIGIBILITY PRIOR TO EACH TIME THEY SEE THE PHYSICIAN
 Definition
TRUE
Term
UNDER A MEDICAID SPEND DOWN PROGRAM, INDIVIDUALS ARE REQUIRED TO SPEND ALL OF THEIR DISCRETIONARY INCOME ON HEALTH COSTS BEFORE MEDICAID BEGINS TO CONTRIBUTE
 Definition
FALSE
Term
CHILDREN UNDER 6 YRS OLD WHO MEET TANF REQUIREMENTS OR WHOSE FAMILY INCOME IS BELOW 133% OF THE POVERTY LEVEL MUST BE OFFERED STATE MEDICAID BENEFITS
 Definition
TRUE
Term
A PERSON ELIGIBLE FOR MEDICAID IN A GIVEN STATE IS ALSO ELIGIBLE IN ALL STATES THAT BORDER ON THE STATE.
 Definition
FALSE
Term
INDIVIDUALS RECEIVING FINANCIAL ASSISTANCE UNDER TANF DUE TO LOW INCOMES AND FEW RESOURCES MUST BE COVERED BY THE STATE MEDICAID PROGRAMS
 Definition
FALSE
Term
TANF
 Definition
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES
Term
INPATIENT CLAIMS FILED BY THE HOSPITAL MUST BE RECEIVED BY MEDICAID WITHIN 95 DAYS FROM THE DISCHARGE DATE
 Definition
TRUE
Term
ALL APPEALS OF DENIED CLAIMS AND REQUEST FOR ADJUSTMENTS ON PAID CLAIMS MUST BE RECEIVED W/IN 180 DAYS FROM THE DATE OF THE R&S REPORT
 Definition
TRUE
Term
THE FEDERAL GOVERNMENT MAKES PAYMENTS TO STATES UNDER THE FEDERAL MEDICAL ASSISTANCE PERCENTAGES (FMAP)PROGRAM
 Definition
TRUE
Term
IMMIGRANTS ARE AUTOMATICALLY EXCLUDED FROM STATE MEDICAL PROGRAMS
 Definition
FALSE
Term
THE MANAGED CARE PCP SERVES AS THE MEDICAL HOME AND THE LIASON BETWEEN THE MEDICAID RECIPIENT AND THE STATE
 Definition
FALSE
Term
WITHIN BROAD NATIONAL GUIDELINES ESTABLISHED BY FEDERAL STATUES, REGULATIONS, AND POLICIES, EACH STATE
 Definition
ADMINISTERS ITS OWN PROGRAM
Term
STATES' ELIGIBILITY GROUPS WILL BE CONSIDERED ONE OF THE FOLLOWING
 Definition
MEDICALLY NEEDY
Term
IF A STATE HAS A MEDICALLY NEEDY PROGRAM, IT MUST INCLUDE
 Definition
PREGNANT WOMEN
Term
WHICH OF THE FOLLOWING PROVIDES STATES WITH GRANTS TO BE SPENT ON TIME LIMITED CASH ASSISTANCE
 Definition
TANF (TEMPORARY ASSISTANCE FOR NEEDY FAMILIES)
Term
MEDI MEDI BENEFITS MAY INCLUDE
 Definition
NUSING FACILITY CARE BEYOND THE 100 DAY LIMIT COVERED BY MEDICARE, PRECRIPTION DRUGS, EYEGLASSES AND HEARING AIDS
Term
WHEN FILING A CLAIM FOR A MALE NEWBORN, IF THE MOTHER'S NAME IS "JANE JONES" THEN THE CLAIM WOULD BE FILED AS
 Definition
BOY JANE JONES
Term
MEDICAID, BY LAW, IS THE _____OF LAST RESORT
 Definition
PAYER
Term
THE ______PROGRAM UNDER MEDICAID OFFERS HEALTH INSURANCE COVERAGE FOR UNINSURED CHILDREN
 Definition
SHIP (STATE CHILDREN'S HEALTH INSURANCE PROGRAM)
Term
PERSONS MAY QUALIFY IMMEDIATELY OR MAY______BY INCURRING MEDICAL EXPENSES THAT REDUCE THEIR INCOME TO OR BELOW THEIR STATE'S MN INCOME LEVEL
 Definition
SPEND DOWN
Term
_______DETERMINE THE AMOUNT AND DURATION OF SERVICES OFFERED UNDER THEIR MEDICAID PROGRAMS.
 Definition
STATES
Term
TWO DIFFERENT MANAGED CARE MODELS ARE______AND_____.
 Definition
PCCM AND HMO'S
Term
AN R&S REPORT IS THE____AND_____REPORT
 Definition
REMITTANCE AND STATUS REPORT
Term
a non availabilabilty statement in the tricare program excuses the beneficiary from paying the cost share
 Definition
false
Term
in the tricare and champva programs, cost share the same meaning as coinsurance
 Definition
TRUE
Term
THE TRICARE PROGRAM SERVES FAMILIES OF VETERANS WITH 100% SEVICE RELATED DISABILITY
 Definition
FALSE
Term
TRICARE PARTICIPATING PROVIDER CHARGES GENERALLY FOLLOW THE MEDICARE FEE SCHEDULE
 Definition
TRUE
Term
IT IS NOT NECESSARY TO COMPETE ALL FORM LOCATORS ON THE CMS-1500 FORM WHEN COMPLETING A TRAICARE CLAIM
 Definition
TRUE
Term
THE TRICARE PROGRAM THAT OFFERS FEE-FOR SERVICE COVERAGE IS
 Definition
TRICAREA STANDARD
Term
THE TICARE PROGRAM THAT OFFERS AN ALTERNATIVE MANAGED CARE PLAN TO TRICARE PRIME WITH NO ENROLLMENT FEE IS
 Definition
TRICARE EXTRA
Term
TRICARE STANDARD
 Definition
A FEE FOR SERVICE PLAN
Term
A SERVICE THAT IS NOT COVERED UNDER TRICARE STANDARD IS
 Definition
CHIROPACTIC CARE, COSMETIC SURGERY, ROUNTINE PHYSICIAL EXAMINATIONS, ALL OF ABOVE
Term
PROFESSIONAL AND INSTRUCTIONAL TRICARE CLAIMS MUST BE SUBMITTED TO PGBA WITHIN HOW MANY DAYS FROM THE DATE OF SERVICE, OR INPATIENT DISCHARGE
 Definition
30 DAYS
Term
THE_____MANAGER IS THE PROVIDER WHO COORDINATES CARE OF TRICARE BENEFICIARIES
 Definition
PRIMARY CARE
Term
THE WORLDWIDE DATABASE OF TRICARE AND CHAMPVA BENEFICIARIES IS
 Definition
(DEERS)-DEFENSE ENROLLMENT ELIGIBILITY REPORTING SYSTEM
Term
THE TRICARE FISCAL YEAR BEGINS____AND ENDS___.
 Definition
OCT 1 AND SEPT 30
Term
AN ONLINE CLAIMS SUBMISSION PROGRAM PROVIDED BY PGBA IS CALLED
 Definition
X PRESS CLAIM
Term
A TRICARE BENEFICIARY WHO LIVES WITHIN A CERTAIN DISTANCE OF A MILITARY HOSPITAL MUST FILE A(N)
 Definition
NON AVAILABLE STATEMENT
Term
TRICARE PHYSICIAN CHARGES ARE FILED USING THE____CLAIM FORM
 Definition
CMS-1500
Term
PAPER CLAIMS FOR CHAMPVA ARE SUBMITTED TO THE_____DEPARTMENT OF THE VA HEALTH ADMINISTRATION CENTER
 Definition
FEE
Term
PAPER CLAIMS FOR CHAMPVA ARE SUBMITTED TO THE_____DEPARTMENT OF THE VA HEALTH ADMINISTRATION CENTER
 Definition
FEE
Term
ALL ENROLLEES IN TRICARE_____MUST BE ENROLLED IN MEDICARE PARTS A AND B
 Definition
SENIOR PRIME
Term
TRICARE______AND_______REQUIRE ENROLLMENT
 Definition
PRIME AND TRICARE PRIME REMOTE
Term
ACTIVE DUTY SERVICE MEMBERS WHO ARE NOT NEAR SOURCES OF MILITARY CARE QUALIFY FOR______
 Definition
TRICARE PRIME REMOTE
Term
THE ALLOWED CHARGE IS THE AMOUNT THAT A THIRD PARTY PAYER WILL PAY FOR PARTICULAR PROCEDURE WHEN THE PATIENT HAS COINSURANCE
 Definition
FALE
Term
ACCOUNTS RECEIVABLE INCLUDE MONIES OWED TO A PRATICE BY BOTH PAYERS AND PATIENTS
 Definition
TRUE
Term
AN ADJUSTMENT IS A NEGATIVE OR POSITIVE CHANGE TO AN ACCOUNT BALANCE
 Definition
TRUE
Term
THE CLAIM TURNAROUND TIME IS THE PERIOD BETWEEN THE PATIENT'S ENCOUNTER AND THE TRANSMISSION OF THE RESULTING CLAIM
 Definition
FALSE
Term
A PAYER MAY DOWNCODE A PROCEDURE IT DETERMINES WAS NOT MEDICALLY NECESSARY AT THE LEVEL REPORTED
 Definition
TRUE
Term
A MEDICAL REVIEW IS PART OF THE PROVIDER'S STAFF RESPONSIBILITIES
 Definition
FALSE
Term
THE DETERMINATION OF A CLAIM REFERS TO THE PAYERS DECISION REGARDING PAYMENT
 Definition
TRUE
Term
WHEN A PAYER'S ERA IS RECEIVED, THE MEDICAL OFFICE SPECIALIST CHECKS THAT THE AMOUNT PAID MATCHES THE EXPECTED PAYMENTS
 Definition
TRUE
Term
UNDER A PLAN WITH AN INDIVIDUAL DEDUCTIBLE AMOUNT CAN BE MET BY THE COMBINATION OF PAYMENTS FROM ALL FAMILY MEMBERS
 Definition
FALSE
Term
POSTING THE PAYMENT TO THE SPECIFIC DATE OF SERVICE AND EACH CPT CODE, AND THEN FOLLOWING THE SAME FOR PROCEDURE FOR POSTING AN adjustment is referred to as per line item posting
 Definition
true
Term
the provider "withhold" required by some managed care plans may be repaid to the phyisican
 Definition
true
Term
THE ADVANTAGES OF USING ETFs ARE THAT FUNDS ARE IMMEDIATELY AVAILABLE AND THE TRANSFER IS LESS COSTLY THAN CHECK DEPOSITS
 Definition
TRUE
Term
THE THREE PARTS OF AN RBRVS(RESOUCE-BASED RELATIVE VALUE SCALE)fee are
 Definition
uniform VALUE, GPCI, AND CONVERSION FACTOR
Term
THE PURPOSE OF THE GPCI IS TO ACCOUNT FOR
 Definition
REGIONAL DIFFERENCES IN COST
Term
WHICH OF THE FOLLOWING PAYMENT METHODS IS THE BASIS FOR MEDICARE'S FEES?
 Definition
RBRVS
Term
THE MEDICARE CONVERSION FACTOR IS SET
 Definition
ONCE EACH YEAR
Term
WHICH ANSWER CORRECTLY LISTS THE MAIN METHOD(s) PAYERS USE TO DETERMINE THEIR FEE STRUCTURE
 Definition
ALLOWED CHARGES, CONTRACTED FEE SCHEDULE, AND CAPITATION
Term
THE MEDICARE ALLOWED CARGE FOR A PROCEDURE IS $80.00 . WHAT AMOUNT DOES THE PARTICIPATING PROVIDER RECEIVE FROM MEDICARE AND WHAT AMOUNT FROM THE PATIENT?
 Definition
$64.00/ $16.00
Term
THE MEDICARE ALLOWED CHARGE FOR A PROCEDURE IS $150.00, AND PAR PROVIDER'S USUAL CHARGE IS $200.00. WHAT AMOUNT MUST THE PROVIDER WRITE OFF?
 Definition
$50.00
Term
THE DEDUCTIBLES, COINSURANCE, AND OVERPAYMENTS PATIENTS PAY CARE CALLED EITHER
 Definition
OUT OF POCKET EXPENSES
Term
IF A NON PAR PROVIDER'S USUAL FEE IS $600, THE ALLOWED IS 300, AND BALANE BILLING IS PERMITTED WHAT AMOUNT IS WRITTEN OFF
 Definition
0.00
Term
A PAYER AUTOMATED CLAIM EDITS MAY RESULT IN CLAIM DENIAL BECAUSE OF
 Definition
LACK OF ELIGIBILITY FOR A REPORTED SERVICE, LACK OF MEDICAL NECESSITY, Lck od required preauthorization
Term
a claim that is removed from a payer's automated processing system is
 Definition
manual review
Term
if a provider has ACCEPTED ASSIGNMENT, THE PAYER SENDS THE ERA OR EOB TO
 Definition
THE PROVIDER
Term
THE PAYER'S DECISION REGARDING WHETHER TO PAY A CLAIM IS CALLED
 Definition
DETERMINATION
Term
AFTER THE CLAIM HAS GONE THROUGH THE ADJUICATION PROCESS AND A CLIAM HAS BEEN DOWNCODED OR DENIED, THE MOS MAY SUBMIT TO THE INSURANCE CARRIER
 Definition
A LETTER OF APPEAL
Term
AN INTIAL REVIEW OF EACH CLAIM CONSISTS____ THAT SCREEN THE BASIC DATA ON THE CLAIM FORM
 Definition
COMPUTER EDITS
Term
ALTHOUGH ADJUDICATION VARIES SOMEWHAT DEPENDING ON THE PAYER'S POLICIES, THE ESSENTAIL STEPS--EDITS, REVIEWS AND _____ ARE UNIVERSAL
 Definition
DETERMINATION
Term
A CLAIM EXAMINER REVIEWS THE CLAIM TO CHECK IF THE______ and ____are linked
 Definition
diagnosis and procedure
Term
downcoding is also called___________
 Definition
medicall necessary reduction
Term
UNDER THE FORMULA FOR CLACULATING A MEDICARE FEE FOR A PROCEDURE, THE SUM OF THE ADJUSTED TOTALS FOR WORK, PRACTICE EXPENSE, AND MALPRACTICE ARE MULTIPLED BY A(n)
 Definition
CONVERSION FACTOR
Term
A(N)_____IS AN AMOUNT THAT AN INSURED MUST PAY TO THE PROVIDER BEFORE THE INSURANCE BENEFITS BEGIN
 Definition
DEDUCTIBLE
Term
IF A PARTICIPATING PROVIDERS'S USUAL CHARGE IS HIGHER THAN THE ALLOWED AMOUNT, THE PROVIDER MUST________THE DIFFERENCE BETWEEN THE TWO CHARGES
 Definition
WRITE OFF
Term
MEDICAL INSURANCE PLANS REQUIRE PATINETS TO PAY FOR ALL________ SERVICES
 Definition
EXCLUDED
Term
FOLLOWING A PAYMENT______, THE PAYER EITHER PAYS, DENIES, OR PARTIALLY PAYS THE CLAIM
 Definition
DETERMINATION
Term
A PAYER MAY DOWNCODE A CLAIM IF THE REPORTED PROCEDURE DOES NOT MATCH THE REPORTED
 Definition
DIAGNOSIS
Term
CORRECTIONS, CHANGES, AND WRITE OFFS TO PATIENTS' ACCOUNT ARE MADE WITH_______ TO THE EXISTING TRANSACTIONS
 Definition
ADJUSTMENTS
Term
IF A CARRIER HAS CONTINUED TO DENY ALL OF THE PRACTICE'S APPEAL REQUESTS, THE PROVIDER CAN FILE A REQUEST TO THE________FOR ASSISTANCE
 Definition
INSURANCE COMMISSIONER
Term
SOME APPEALS MAY BE CONDUCTED OVER THE TELEPHONE, WHEREAS OTHERS MAY REQUIRE A WRITTEN APPEAL
 Definition
TRUE
Term
IF A PAYER HAS REJECTED ALL OF THE APPEALS ON A CLAIM, THE CLAIMANT MAY TAKE THE CASE TO THE STATE'S INSURANCE COMISSIONER
 Definition
TRUE
Term
THE MEDICARE PROGRAM PROVIDES FOUR LEVELS OF APPEALS
 Definition
FALSE
Term
THE MEDICARE PROGRAM PROVIDES FOUR LEVELS OF APPEALS
 Definition
FALSE
Term
THE SOAP FORMAT IS USED WHEN CALLING INSURANCE COMPANIES TO VERIFY BENEFITS
 Definition
FALSE
Term
WHEN A THIRD PARTY PAYER ISSUES A REFUNC REQUEST IN WRITING THE PRACTICE SHOULD ISSUE A REFUND WITHIN 24 HOURS
 Definition
FALSE
Term
ERSA STANDS FOR EMPLOYEE RETIREMENT INCOME SECURITY ACT (OF 1974)
 Definition
TRUE
Term
EACH STATE'S INSURANCE COMMISSIONER IS THE REGULATORY AGENC;Y FOR THE INSURANCE INDUSTRY AND SERVES AS A LIAISON BETWEEN THE PATIENT AND THE PROVIDER
 Definition
TRUE
Term
REGARDLESS OF THE METHOD OF REIMBURSEMENT, INSURANCE CLAIMS MUST BE MONITORED UNTIL PAYMENTS ARE RECEIVED
 Definition
FALSE
Term
THE GOVERNMENTAL DEPARTMENT YOU SHOULD GO TO IF MULTIPLE APPEALS TO AN MCO FAIL IS
 Definition
THE STATE DEPARTMENT OF INSURANCE/ INSURANCE COMMISSIONER
Term
WHAT % OF DENIED CLAIMS ARE OVERTURNED ON THE FIRST APPEAL
 Definition
25%
Term
IF YUR FIRST APPEAL IS DENIED, IT IS APPROPRIATE TO
 Definition
WRITE A SECOND APPEAL
Term
IT IS BEST TO DIRECT INITIAL APPEAL LETTERS TO
 Definition
THE CLAIMS EXAMINER
Term
THE METHODS OF DOCUMENTATION MOST WIDELY USED BY PHYSICIANS IS THE
 Definition
SOAP FORMAT
Term
WHAT % OF DENIED CLAIMS ARE OVERTURNED ON THE SECOND APPEAL
 Definition
25%
Term
APPEALING DENIED INSURANCE CLAIMS REQUIRES
 Definition
PERSERVERANCE
Term
MEDICARE PART B STATES THE NUMBER ONE REASON AN APPEAL IS RETURNED IS BECAUSE
 Definition
IT IS INVALID OR THERE IS NO ACCEPTABLE SIGNATURE
Term
ADMINISTRATIVE LAW JUDGE (ALJ) HEARING
 Definition
THIRD LEVEL OF MEDICARE APPEAL
Term
DOCUMENTATION
 Definition
AN EXAMINATION AND VERIFICATION OF CLAIMS AND SUPPORTING DOCUMENTS BY A PHYSICIAN OR MEDICAL FACILITY
Term
CLAIM APPEAL
 Definition
A WRITTEN REQUEST FOR A REVIEW OF REIMBURSEMENTS
Term
PEER REVIEW
 Definition
AN OBJECTIVE UNBAISED GROUP OF PHYISICANS WHO DETERMINE WHAT PAYMENT IS ADEQUATE FOR SERVICES PROVIDES
Term
INSURANCE COMISSIONER
 Definition
THE REGULATORY AGENCY FOR THE INSURANCE INDUSTRY; SERVES AS A LIAISON BETWEEN THE PATIENT AND THE CARRIER
Term
SOAP
 Definition
A METHOD OF DOCUMENTATION MOST WIDELY USED BY PHYSICIANS FOR RECORD KEEPING
Term
AUDIT
 Definition
A PROCESS OF EXAMINING and verifying claims and supporting documents submitted by a physician or medical facility
Term
workers compensation bills need to be submited with a
 Definition
status report
Term
MMI
 Definition
MAXIMUM MEDICAL IMPROVEMENT
Term
AN INJURED WORKER MAY NOT RECEIVE BENEFITS IF
 Definition
THE INJURY OCCURED WHILE WORKER IS INTOXICATED
Term
_______DESCRIBES THE DEGREE OF THE PERMANENT DAMAGE DONE TO A WORKERS BODY AS A WHOLE
 Definition
IMPAIRMENT RATING
Term
CARPAL TUNNEL SYNDROME IS AN EXAMPLE OF A(N)________ILLNESS
 Definition
OCCUPATIONAL
Term
WHEN A PERSON KNOWNINGLY OR INTENTIONALLY CONCEALS, MISREPRESENTS OR MAKES A FALSE STATEMENT TO EITHER DENY OR OBTAIN WORKER'S COMP BENEFITS OR INSURANCE COVERAGE OR OTHERWISE PROFITS FROM DECEIT THIS ACTION IS CALLED
 Definition
FRAUD
Term
IN THE WORKERS COMP CLASSIFICATION OF INJURIES, AN INJURY REQUIRING_______ OCCURS WHEN A WORKER IS INJURED ON THE JOB AND CANNOT RESUME WORK WITHOUT RETRAINING
 Definition
VOCATIONAL REHAB
Term
IN THE WORKERS COMP CLASSIFICATION OF INJURIES,________INJURY OCCURS WHEN A WORKER IS INJURED ON THE JOB AND CANNOT RESUEM WORK WITHIN A FEW DAYS OF RECEIVING TREATMENT
 Definition
TEMPORARY DISABILITY
Term
IN THE WORKERS' COMP CLASSIFICATION OF INJURIES,________INJURY OCCURS WHEN A WORKER IS INJURED ON THE JOB, IS UNABLE TO RESUME WORK, AND IS NOT EXPECTED TO BE ABLE TO RETURN TO THE REGULAR JOB IN THE FUTURE
 Definition
PERMANENT
Term
THE FEERAL EMPLOYEE'S COMPENSATION ACT PROVIDES______ INSURANCE FOR CIVILIAN EMPLOYEES OF THE FEDERAL GOVERNMENT
 Definition
DISABILITY
Term
________ IS THE PERMANENT PHYSICAL DAMAGE TO A WORKER'S BODY FROM A WORK RELATED INJURY OR ILLNESS
 Definition
IMPAIRMENT
Term
WHATO LOCATORS ARE LEFT BLANK ON A CMS-1500 CLAIM FORM FOR A WORKERSRS COMP CLAIM
 Definition
FORM LOCATORS 12 AND 13
Term
WORKERS' COMP FEES ARE BASED ON WHAT FEE SCHEDULE AND A %
 Definition
MEDICARE
Term
WHT INFORMATION IS REQUIRED IN FORM LOCATOR 1a WHEN PREPARING A WORKER'S COMPENSATION CLAIM
 Definition
PATIENT'S SOCIAL SECURITY NUMBER
Term
SUPPLEMENTAL SECURITY INCOME PROVIDES FINANCIAL ASSISTANCE TO INDIVIDUALS
 Definition
ARE QUALIFIED FOR WELFARE PROGRAMS
Term
SOCIAL SECURITY DISABILITY INSURANCE PROVIDES COMPENSATION FOR LOST WAGES TO INDIVIDUALS WHO
 Definition
HAVE CONTRIBUTED TO SOCIAL SECURITY
Term
WHEN A PROVIDER INITIALLY EXAMINES A WORKER'S COMPENSATION PATIENT, WHAT DOCUMENT MUST BE FILED WITH THE STATE
 Definition
WORK STATUS REPORT
Term
AFTER DISCARGING A WORKERS' COMPENSATION PATIENT, THE PROVIDER MUST FILE A (n)
 Definition
FINAL REPORT
Term
DISABILITY COMP PROGRAMS REIMBURSE THE INSURED ONLY WHEN A WORK RELATED INJURY CAUSES THE PERSON TO LOSE INCOME
 Definition
TRUE
Term
THE ADMISSION OF LIABILITY AN THE NOTICE OF CONTEST DETERMINATINS BOTH FINE THE EMPLOYER LIABLE IN A WORKERS' COMP CASE
 Definition
FALSE
Term
AN OCCUPATIONAL DISEASE OR ILLNESS IS CAUSED BY SOME FACTOR IN THE WORK, ENVIROMENT THAT EXISTS OVER A PERIOD OF TIME
 Definition
TRUE
Term
UNDER WORKERS COMP REGULATIONS, THE TREATING DOCTOR IS THE PROVIDER WHO PREPARES THE FIANL REPORT
 Definition
TRUE
Term
FECA
 Definition
FEDERAL EMPLOYEES' COMPENSATION ACT
Term
DISABILITY MEANS LOSS OF INCOME
 Definition
TRUE
Term
DISABILITY COMPENSATION PROGRAMS DO NOT PAY MEDICAL BENEFITS
 Definition
TRUE
Term
OSHA
 Definition
OCCUPATIONAL SAFETY AND HEALTH ACT
Term
VOCATIONAL REHABILITATION IS NOT COVERED BY WORKERS' COMPENSATION PLANS
 Definition
False
Term
THE EMPLOYER SENDS IN THE FINAL REPORT OF INJURY OR ILLNESS IN A WORKERS' COMP CASE
 Definition
TRUE
Term
THE FEE FOR WORKERS COMP CASES ARE BASED ON THE UCR FEE
 Definition
FALSE
Term
ANY EMPLOYEE CAN PURCHASE A DISABILITY PLAN
 Definition
TRUE
Term
IME
 Definition
INDEPENDANT MEDICAL EXAMINATION
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