Claim Cycle
This is the document submitted to the payer requesting reimbursement.
Health insurance claim
This is health insurance coverage subsidized by employers and other organizations, which distributes the cost of health plans among members.
Group Health Insurance
This is the fixed amount the patient must pay each time they receive services.
Copayment
This type of provider is responsible for supervising and coordinating health care services for enrollees.
Primary Care Provider
Part ____ bundles Parts A and B, also called Medicare Advantage.
C
This is a report is sent to the patient by the payer to clarify the results of claims processing.
Explanation of Benefits
This is a name for any health insurance company that provides coverage, such as Medicare or BlueCross BlueShield.
Third-party payer
This is the person who signs a contract with a health insurance company and owns the policy.
Policyholder
This coding system is used to report diseases, conditions, and injuries on claims.
ICD-10-CM
Medicare Part _____ helps cover inpatient care in acute care hospitals.
A
This is the process of reporting diagnoses and procedures/services as numeric and alphanumeric characters on the insurance claim.
Coding
Do patients using in-network providers generally pay higher or lower out-of-pocket costs than patients using out-of-network providers?
lower
This is the specified percentage of charges the patient must pay to the provider for each service received or for each visit.
Coinsurance
Name an example of a Managed Care Organization (MCO).
Hospital, physician group, health plan, health system
Part ____ helps cover physician services and outpatient hospital care .
B
This process involves linking every procedure/service code reported on the claim to a condition code that justifies the necessity of that procedure or service.
Medical necessity
A patient is injured in a car accident and has coverage with Medicare and automobile insurance. Which plan is responsible for paying the claim first?
automobile insurance
This is the amount for which the patient is financially responsible before an insurance policy provides payment.
Deductible
What is the primary purpose of the patient record?
Providing continuity of care
Medicare Part _____ offers optional prescription drug coverage to Medicare beneficiaries.
D
These two coding systems are used to report procedures and services on CMS-1500 claims.
CPT and HCPCS level II
___________ includes federal and state government health programs available to eligible individuals.
Public health insurance
This record includes the collection of one patient’s information documented by a number of different providers. It offers access to complete and accurate patient health information.
Electronic Health Record (EHR)
CMS stands for...
Centers for Medicare and Medicaid Services
Medicare Supplementary Insurance is also known as ________.
Medigap