what
A hold harmless clause means the patient:
is not responsible to pay what the insurance does not cover
embezzle means to:
steal
when an insurance plans prior approval is not met - what happens?
payment of claim is denied
what type of health insurance is subsidized by employers and other organizations ?
group health insurance
what type of insurance covers employees and dependants against injury and death that occurs during course of employment?
workers comp
what "term" means the provider agrees to accept what the insurance allows as payment in full for the claim >
accepts assignment
Title XIX of the social security act is a cost sharing program known as:
medicaid
An MCO is responsible for the health of a group of _______ it can be a health plan, hospital, physician group or health system
enrollees
A PAR _(is or is not)____allowed to bill patients for the difference between the contracted rate and their normal fee
is not
CLIA legislation established this for all the centers where testing is perfomed
quality standards
Managed health care was developed as a way to provide affordable and comprehensive prepaid health care services to who?
enrollees
a secondary insurance is billed after the primary has paid and the providers office has received a/an ______ from the primary payor
RA
what is the electronic or manual submission of claim data to payers or clearinghouses for processing called
claims submission
a claims examiner is employed by:
3rd party payor to review claims
what is the financial source document in office setting to record diagnosis and services that were rendered during the current visit?
superbill / (encounter form)
claim adjudication involves making a determination about ______charges, which is the maximum amount the payor will permit for each procedure
allowed
3rd party determined the allowed amt is $100, for which the provider is reimbursed 80% and patient is responsible for the other 20%. The provider will receive a check in the amt of _____ from the payor and the pt will have to pay the provider ________
80/20
the optical scanning process uses a device that converts ____ characters into text that can be viewed by the OCR (optical character reader)
printed
what involves sorting claims upon submission to collect and verify information about the pt and provider called
claim processing
what do health information technicians do?
manage medical records
secondary diagnosis are entered into which blocks on the CMS 1500 ?
21B- 21L
Institutional and other selected providers submit _(name)____ claim(s) to request payment from payors
UB04
with managed care's capitation method, if the physician provides services that cost less than the capitation amount - what happens to that money ?
keeps it to reinvest in the medical practice
when a person uses a title such as: Sr, Jr, II etc, what do we do with that on the CMS 1500 form ?
do not enter it unless it is on the insurance ID card
Surgeons charges for inpatient and outpatient surgery are billed according to a global fee, which means the preop evaluation, the initial and subsequent hospital visits, surgical procedure , discharge visit and post op follow up in the surgeons office are covered under how many charges?
one (global package) (10/30/90)
which insurance claim(s) is/are submitted to receive reimbursement under medicare Part A ?
UB04
People who wait until they turn 65 to apply for Medicare will cause a delay in Part B coverage, because they will have to wait until the next ________ which is January 1 - March 31 of each year with Part B starting July 1st of that year ?
general
Medicare benefit period begins the 1st day of hospitalization and ends when the pt has been out of the hospital _____ consecutive days
60
What is the identification of disease and the provision of care and treatment to persons who are sick, injured or concerned about their health status called ?
medical care
which program pays for inpatient hospital, critical care, skilled nursing facilities, and some home health care ?
Medicare part A
An ABN must be presented, explained and signed by the patient when ?
BEFORE providing that service or procedure
in 1965 congress passed the Title 19 of the social security act, establishing a federally mandated, ______ administered medical assistance program
state
when a pt is covered by other medical or liabilty policy, Medicare reimburses the provider _____
last
federal regulations require medicaid to establish and maintain a/an _________ program which safeguards against unnecessary use of Medicaid services, or excessive payments
surveillance and utilization review
which is a health care program for active duty members of the military and their families
tricare
commaders of selected military treatment facilities are called ____for tricare regions
lead agents
when a pt seeks healthcare under the Tricare program, sponsor information is found in the ______ system
DEERS
Tricare _____ are available 24/7 for advice and assistance with treatment alternatives and whether a sponsor should see a provider
nurse advisors
who is required to personally sign the original and all photocopies of reports submitted to the workers comp board ?
provider / physician
who is responsible for paying all charges on an account?
guarantor
which insurance plan is responsible for paying health care claims first >
primary insurance
a child lives with both parents - both have health insurance. The one that holds the primary policy for the dependant children is the spouse whose birth......
month and day are earlier in the calendar year
when applying the birthday rule, if the policy holders have identical birthdays, but different years, which policy is in effect as primary ?
the one who has had the policy the longest
A child is listed on both parents policies. Dad was born March 20, 1977 and mom was born March 6, 1979. Who is primary>
mothers policy
a policyholder or ______ is the person in whose name the insurance policy was issued
beneficiary
an appeal is documented as a/an _______ why a claim should be reconsidered for payment
letter signed by provider explaining
a pre-existing condition is any medical condition that was diagnosed and/or treated _____ the enrollee's effective date of coverage
before
what is submitted to the payor requesting reimbursement?
health insurance claim
what is latin for "let the master answer"
respondeat superior
a Non-par is out of network and the pt will usually have higher costs. The patient is _(is or is not)____ expected to pay the difference between the insurance payment and the providers fee
usually is