Managed Care
This is a voluntary process that health care facility or organization (e.g., hospital or managed care plan) undergoes to demonstrate that it has met standards beyond those required by law.
What is Accreditation?
This is the amount owed to a business for services or goods provided.
What is accounts receivable?
This is a unique identifier assigned to health care providers as a 10-digit numeric identifier, including a check digit in the last position.
What is a National Provider Identifier (NPI)?
This is the code book used for diagnosis coding.
What is ICD-10-CM?
These are the item letters A through L preprinted in Block 21 of the CMS-1500 claim. These are known as _______ pointers.
What are diagnosis pointers?
This is a payment methodology where the provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year).
What is capitation?
This determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan.
What is the birthday rule?
This is an organization that is contracted to process Medicare claims, previously called a fiscal intermediary.
What is a Medicare Administrative Contractor (MAC)?
This is a disease or syndrome named for a person; listed in appropriate alphabetical sequence as main terms in the index.
What is an eponym?
This is an outline format for documenting health care; ____ is an acronym derived from the first letter of the headings used in the note (4 letters).
What is SOAP? Subjective, Objective, Assessment and Plan.
This is a primary care provider for essential health care services seeking to provide quality care at the lowest possible cost, working to avoid nonessential care, and referring patients to specialists.
What is a gatekeeper?
This is the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
What is a coinsurance?
This is a legal newspaper published every business day by the National Archives and Records Administration (NARA).
What is the Federal Register?
This is a concurrent condition that coexists with the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), has the potential to affect treatment of the first-listed diagnosis (outpatient care) (or principal diagnosis for inpatient care), and is an active condition for which the patient is treated and/or monitored.
What is a co-morbidity?
These plans will cover the deductible and copay or coinsurance of a primary health insurance policy.
What is a supplemental plan?
These are created standards to assess managed-care systems using data elements that are collected, evaluated, and published to compare the performance of managed health care plans. Some standards include mammogram compliance, etc.
What are Healthcare Effectiveness Data and Information Set (HEDIS) measures?
This is how the provider accepts as payment in full whatever is paid on the claim by the payer (except for any copayment and/or coinsurance amounts). (The Y is checked for Yes in this box.)
What is accept assignment?
This is also called common law and is based on a court decision that establishes a precedent.
What is case law?
This is the code book used to identify services and procedures provided to the patient.
What is CPT?
This is the insurance claim or flat file used to bill institutional services, such as services performed in hospitals.
What is a UB-04?
This is usually owned by physicians or a hospital and provides practice management (administrative and support) services to individual physician practices.
What is a managed service organization (MSO)?
This is the process of comparing a claim to payer edits and the patient’s health plan benefits to verify that the required information is available to process the claim; the claim is not a duplicate; payer rules and procedures have been followed; and procedures performed or services provided are covered benefits.
What is claims adjudication?
This is the assignment of an ICD-10-CM diagnosis code that does not match patient record documentation for the purpose of illegally increasing reimbursement (e.g., assigning the ICD-10-CM code for heart attack when angina was actually documented in the record) or billing for a level of service higher than indicated in the record.
What is upcoding?
This is the code book used when supplies are provided to the patient such as walker, wheelchair, drugs, splints, etc.
What is HCPCS?
This involves assigning ICD-10-CM codes to diagnoses and CPT/HCPCS level II codes to procedures/services, and then matching an appropriate ICD-10-CM code with each CPT or HCPCS level II code.
What is medical necessity?