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26 Cards in this Set
- Front
- Back
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Beneficiary
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The person receiving the benefits of an insurance policy.
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Birthday Rule
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The rule governing the hierarchy of coordination of benefits.
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COB (Coordination of Benefits
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The provision in an insurance contract that limits benefits to 100% of the cost
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Capitation |
A method of payment for health services in which an individual provider is paid a fixed, per capita amount for each person served without regard to the actual number or nature of services provided to each person. |
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Premium
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The periodic payment required to keep a policy in force
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Claim
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A demand to the insurer by the insured person for the payment of benefits under a policy
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Deductible
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A statement in an insurance policy that the insuring company will pay the expenses incurred after the insured person has paid a specific amount
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CMS
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Centers for Medicare and Medicaid Services (CMS), formerly known as Health Financing Administration (HCFA)
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Superbill |
Is an Encounter form/Charge slip, intake form. Make certain that the code descriptions on the superbill match those listed in the latest CPT code book |
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HMO |
WHAT IT IS:A health maintenance organization (HMO) is a health insurance provider with a network of contracted healthcare providers and facilities. Subscribers pay a fee for access to services within the HMO's network. |
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Crossover Claim
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A claim for benefits under both Medicare and Medicaid
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ICD-10
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(International Classification of Diseases, 10th Revision, Clinical Modification) a system for classifying diseases and operations to facilitate collection of uniform and comparable health
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Medicare
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Medicare under the Social Security for the patient over 65 years of age went into effect in July 1, 1966. The law expanded in 1973, this included disabled worker, persons who became incapacitated before age 22 years, disabled widown, and disabled dependent widows.
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Medicaid
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Under the Social Security Amendment of 1965, provided for agreement with states for assistance from the federal government in providing health care for the medically indingent (needy) and is known as Medicaid
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CHAMPVA
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Stablished for the spouses and dependent of veterans suffering total, permanent, service-connected disabilities and for the surviving spouses and dependent children of veterans who have died as a result of service-connected disabilities. This is called CHAMPVA (Civilian Health and Medical Program of the Veterans Administration)
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TRICARE
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Covers active military men and woman. Dependents of military personnel receive in-hospital treatment by civilian physicians at the expense of the government. Military retireess and their dependents as well as dependents of deceased members became eligible for outpatient benefits, except that their co-payment amount is 25% after the deductible. In order to receive TRICARE benefits, eligible persons must be enrolled in the Defense Enrollment Eligibility System (DEERS), a computerized database that is used for verifying eligibility.
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Worker's Compensation
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All state legislatures have pased worker's compensation laws to protect wage earners against the loss of wages and the cost of medical care resulting from occupational accident or disease. Does not cover spouses or dependents,
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CPT-4
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Physician's Current Procedural Terminology (CPT-4) . CPT-4 is a listing of descriptive terms and identifying codes that is used for reporting medical services and procedures performed by physicians.
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2 common types of medical coding |
Two common medical coding classification systems are in use — the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT). ICD is the standard international system of classifying mortality and morbidity statistics, and it’s used by more than 100 countries. The system is used by health care facilities to define diseases and allocate resources to provide care. |
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ICD-9 |
The ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) coding system, connects health issues that arise in patients, by using three- to five-digit alphanumeric codes to indicate signs, symptoms, diseases, conditions, and injuries to payers injuries, diseases, and conditions. These codes are used in conjunction with CPT (procedural) codes to record services rendered by a provider to a patient and is documented in the medical record and then reported to a payer for reimbursement. |
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Stark Law |
The physician referral law (section 1877 of the Social Security Act) prohibits a physician from referring patients to an entity for a designated health service (DHS), if the physician or a member of his or her immediate family has a financial relationship with the entity, unless an exception applies. |
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Five Reasons for Claim Rejection |
1. Diagnosis is missing or incomplete 2. Diagnosis is not coded accurately 3. Diagnosis does not correspond with treatment 4. Charges are not itemized 5. Patient's group, member, or policy number is missing or incorrect 6. Patient's portion of the form is incomplete or the patient's signature is missing. 7. Patient's date of birth is missing 8. Fee is not listed 9. Dates are incorrect 10. Doctor's signature or address is missing |
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What is SSI |
Supplemental Security Income (SSI) is a United States government program that provides stipends to low income people who are either aged 65 or older, blind, or disabled. Although administered by the Social Security Administration, SSI is funded from the U.S. Treasury general funds, not the Social Security trust fund. |
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AMA |
American medical association, they compile CPT codes |
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Subscriber |
A person named as principal in an insurance company |
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CPT-4 |
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