Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
35 Cards in this Set
- Front
- Back
|
Medical Necessity |
Involves linking procedure/service codes that you report on the claim to condition (diagnosis codes) which justify the need of performing that service or procedure |
|
|
Health Insurance Claim |
It is the documentation that is submitted to a third party payer or a government program requesting reimbursement for health care services that were provided. |
|
|
EOB |
Explanation of Benefits - A report which is sent to the patient by the insurance company which details the results of processing the insurance claim. |
|
|
What two levels are part of the Healthcare Common Procedural Coding System (HCPCS)? |
CPT - Level 1 national codes HCPCS - Level 2 national codes |
|
|
What do health Insurance Specialists, also known as reimbursement specialists, do? |
They review health related claims to determine the medical necessity for procedures or services performed before reimbursement is made to the provider. |
|
|
Coding |
It is the process of reporting diagnosis, procedures, and services as numeric and alphanumeric characters on the insurance claim form. |
|
|
What can you do to reduce coding and billing errors? |
Health insurance specialists need to explain complex insurance concepts and regulations to patients effectively and communicate with providers regarding documentation of procedures and services. |
|
|
What is FLUENCY? |
It is the language of medicine and the ability to use a medical dictionary as a reference are necessary skills for a health insurance specialist. |
|
|
What do the AAPC, AHIMA, and AMBA offer? |
They offer exams leading to the professional credentials. |
|
|
What is a respondeat superior? |
A health care facility (or physician) that employs health insurance specialists is legally responsible for employees' actions performed within the context of their employment. |
|
|
The Department of Labor (DOL) uses the "economic reality" test to determine worker status for purposes of compliance with the minimum wage and overtime requirements of the.... |
Fair Labor Standards Act
|
|
|
The process of assigning ICD-10 and CPT/HCPCS code is called... |
Coding |
|
|
What is medical malpractice insurance? |
It is a type of insurance that covers physicians and other healthcare professionals for liability as to the claims arising from patient treatment. |
|
|
One reason for the increased hiring of insurance specialists is... |
A direct result of employers' attempts to reduce the cost of providing employee health insurance coverage. |
|
|
Claims Examiner |
They are employed by a third party payer and reviews health-related claims to determine whether the charges are reasonable and for medical necessity. |
|
|
Hold Harmless Clause |
The patient is not responsible for paying what the insurance plan pays. |
|
|
Who is the American Medical Association for? |
It is not for professional association for health insurance specialists, but rather for physcians. |
|
|
To remain current with the frequent changes for health insurance processing, the health insurance specialist should... |
Make certain they are on mailing lists to receive newsletters from third-party payers. Remain current on news released by CMS. Stay current with with the DHHS updates. |
|
|
Accurate coding of diagnoses, procedures, and services rendered to the patient allows the medical practice to... |
Facilitate analysis of the practice's patient base for improvement and efficiency and communicate diagnostic and treatment data to insurance plans for maximum recovery of benefits. |
|
|
Who is the CPT manual published by? |
The American Medical Association (AMA) |
|
|
Another name for health insurance specialist is... |
Reimbursement specialist |
|
|
CPT stands for... |
Current Procedural Terminology |
|
|
Each new provider-managed care contract increases by... |
Practices patient data base. Number of claims requirements and reimbursement regulations. Time the office staff must devote to fulfilling contract requirements |
|
|
Successful health insurance specialists should have the following characteristics.... |
Ability to work independently Strong sense of ethics Attention to details |
|
|
ICD-10 means... |
International Classification of Diseases, 10th Revision, Clinical Modification |
|
|
According to the Occupational Outlook Handbook published by the US Department of Labor - Bureau of Labor Statistics, health care facilities and insurance companies will... |
Hire health insurance specialists at an increased rate per year of 9-17% |
|
|
Health insurance specialists and medical assistants obtain employment... |
Clinics Clearinghouses Physician's offices |
|
|
HCPCS Level 2 |
Codes also referred to as National Codes |
|
|
What is Preauthorization? |
The act of obtaining prior approval from the insurance company |
|
|
Why is preauthorization important? |
Without it, the insurance company will deny a claim. |
|
|
Professional liability insurance is also referred to as...
|
Errors and Omissions Insurance |
|
|
You can obtain _____ certification through _____. |
CPC (Certified Professional Coder), AAPC (American Association of Professional Coders) |
|
|
What is Remittance Advice? |
It is the notification the provider receives from the insurance company regarding payment of a claim. |
|
|
Ethics |
Principles of right and good conduct |
|
|
There are four types of insurance that health care providers and facilities typically purchase are... |
Bonding Liability Property Worker's Comp |
