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MED 211
MIDTERM EXAM STUDY GUIDE
50
Insurance
Undergraduate 2
10/31/2012
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Term
__________ is the process of reporting diagnoses, procedure, and services as numeric and alphanumeric characters on the insurance claim form.
 Definition
Coding
Term
Diagnosis codes use _______ coding system.
 Definition
ICD-9-CM
Term
CPT stands for __________ _________ _________
 Definition
Current Procedural Terminology
Term
The two digit code attached to a main code to indicate that the procedure or service has been altered is called a __________.
 Definition
modifier
Term
Each procedure or service on the claim form must be linked to a condition that justifies the ________ _________ of performing the procedure or service. It will determine if a procedure or service will be reimbursed by a payer.
 Definition
medical necessity
Term
When a service or procedure does not match up with an appropriate diagnosis on a claim the procedure is determined to be ___________ __________.
 Definition
medically unnecessary
Term
A company that establishes a utilization management program and performs external utilization review services is a _________ _______________.
 Definition
Review Organization
Term
A managed care clause that prohibits providers from discussing all treatment options with patients is known as __________.
 Definition
gag
Term
A physician or care facility under contract with a manage care plan is known as a _________ __________.
 Definition
network provider
Term
Any information communicated by a patient to a health care provider is considered __________.
 Definition
privileged
Term
The right of individuals to keep their protected health information from being disclosed to others is called __________.
 Definition
privacy
Term
The process of safekeeping patient information is known as _________.
 Definition
security
Term
If a health care professional releases confidential information to a person who has no demonstrable legal need to receive this information is called ____________ ____ ___________.
 Definition
breach of confidentiality
Term
When processing insurance claims, health care professionals must ensure that the patient signed the "___________ ____ _________ ____ _____ __________". Otherwise the claim will be denied.
 Definition
Authorization for Release of Medical Information
Term
Providers must maintain written acknowledgment of patients' right to privacy notification.
 Definition
True
Term
_________________ ___ __________ is the mutual exchange of data between a provider and a payer.
 Definition
Electronic data interchange
Term
Policyholder is also called _________.
 Definition
subscriber
Term
An _____ ______ is a financial source document used by health care providers to record treated diagnosis and services rendered to the patient during the current encounter.
 Definition
encounter form
Term
An encounter form is also known as a __________.
 Definition
superbill
Term
A ________ ____ can be used to create a patient medical record and financial record.
 Definition
registration form
Term
A percentage of health care cost to be paid by the patient is called ____________.
 Definition
coinsurance
Term
The amount the insured must pay before health care benefits are reimbursed is called _____________.
 Definition
deductible
Term
A flat payment made by the insured for each service provided is called __________.
 Definition
copayment
Term
A ___________ is an organization that performs centralized claims processing for providers and health plans.
 Definition
clearinghouse
Term
___________ is a helth care plan designated for people 65 and older.
 Definition
Medicare
Term
___________ covers low income patients.
 Definition
Medicaid
Term
A program that allows individuals to set aside and subsequently withdraw tax-free funds for health expenses is a __________ ___________ __________.
 Definition
medical savings account
Term
The method of reimbursements in which providers accept pre-established payments for providing health care services to enrollees over a period of time is called ______.
 Definition
capitation
Term
___________ ___ ___________ is a report that details to the patient the results of a processed claim.
 Definition
Explanation of benefits
Term
___________ ______ is a permanent record of all financial transactions.
 Definition
Patient ledger
Term
A claim which is correctly completed on a standardized form is known as a _________ _________.
 Definition
clean claim
Term
According to federal regulations providers are to retain copies of any government insurance claim and copies of all attatchments filed by the provider for a period of ____ ________.
 Definition
7 years
Term
Patient information and health insurance records must be maintained for __ _________.
 Definition
6 years
Term
__________ _________ is a medical condition that was diagnosed and/or treated with a specified period of time immediately preceding an enrollee's effective date of coverage.
 Definition
Preexisting condition
Term
An insurance company has the right to cancel a patient's policy if the patient fails to disclose any preexisting conditions.
 Definition
True
Term
___________ _________ is performed to review for medical necessity of inpatient care prior to the patient's admission
 Definition
Preadmission certification
Term
An ______ _____ can be converted in an inpatient admission.
 Definition
observation status
Term
An ___ is a letter written and signed by the provider that explains why a claim should be reconsidered for payment.
 Definition
appeal
Term
A claim is considered delinquent when it is _____ ___ past due.
 Definition
120 days
Term
Funds received by a provider or beneficiaries in excess of amounts due or payable under the Medicare or Medicaid statutes or regulations are called _________________.
 Definition
overpayments
Term
The abbreviation OCR stands for _________ ______ _________ and the main benefit is to increase claims processing productivity.
 Definition
optical character reader
Term
Birth dates are usually entered on the CMS-1500 in the format __ __ ____.
 Definition
MM DD YYYY
Term
The proper way to enter a SS # on the CMS-1500 is without dash or spaces.
 Definition
True
Term
On the claim always leave the _________ ______ ___ _____ entry free.
 Definition
upper right hand section
Term
_____ ______ _________ ________ is the first code to enter in block 21.
 Definition
The first listed diagnosis
Term
A maximum of ______ ICD-9-CM codes may be entered on the CMS-1500 claim.
 Definition
four
Term
Never use a diagnosis as "rule out", "probable", "versus".
 Definition
True
Term
Outpatient surgery and surgeon's charges for inpatient surgery are billed according to the ________ _____.
 Definition
global fee
Term
________ is an important part of the insurance specialist's job.
 Definition
Ethics
Term
_____ means employer identification number and is different from SS.
 Definition
EIN
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