Mod H Theory

Front 1

A specific provider who oversees the entire care in treatment of a patient in an HM OH is called a

Back 1

Primary care physician

Front 2

Many self insured groups hire a specific type of organization to manage and pay claims called

Back 2

Employee retirement services administrator ERSAs an administrative service organizations ASOs

Front 3

A healthcare provider trained in the specific medical specialty is

Back 3

A specialist

Front 4

Policy premiums, yearly deductible and coinsurance are the three out of pocket cost in

Back 4

Fee for service plants

Front 5

The formal term for a written complaint submitted by an individual cover by special plan or policy is called

Back 5

Grievance

Front 6

Today, the blue system is the largest single processor of Medicare claims, which is called

Back 6

Fiscal intermediary

Front 7

A private, nonprofit organization that acredits health care given to plan members is the

Back 7

NCQA

Front 8

Many fee for service policies set a limit for what they will reimburse their members for any charges incurred, which is referred to as

Back 8

Lifetime insurance cap

Front 9

A type of HMO whereby services are provided by outpatient networks composed of individuals health care providers who supply all necessary patient care is a

Back 9

IPA

Front 10

The four basic types of health insurance fall into two broad categories, which are

Back 10

Indemnity, managed care

Front 11

participating providers contracting with Blue Cross Blue Shield must file claims within 365 days following the last date of service provided to the patient. This is referred to as

Back 11

Timely filing

Front 12

The private, not-for-profit organization dedicated to improving health care quality and frequently referred to as the managed care watch dog is

Back 12

NCQA

Front 13

To reduce unnecessary impatient, outpatient services uses

Back 13

Utilization

Front 14

A request by a healthcare provider for his or her patients to be evaluated or treated by a specialist

Back 14

Referral

Front 15

When the employer, not the insurance company -is responsible for the cost of medical services, is referred as

Back 15

Self self-insurance

Front 16

When a patient is sent to another provider with the intent of rendering an expert opinion on a specific health complaint, it is called

Back 16

A consultation

Front 17

a document prepared by the carrier that gives details of how a claim was adjudicated is called

Back 17

Explanation of benefits

Front 18

With many MCO s, the enrollee typically pace a small fee upfront when visiting his or her PCP call a

Back 18

Copayment

Front 19

Many Americans obtain health insurance owing to their employment through what is commonly referred to as

Back 19

Group insurance

Front 20

A group of health care providers working under one umbrella to provide medical services at a discount to the individuals who participate in the plan is referred to as

Back 20

PPO, prefer provider organization

Front 21

water the plane types within managed care plans

Back 21

Perferred providers organization PPO, health maintenance organization HMO, Point of Service POS plans

Front 22

Individuals who are members of a managed care plan

Back 22

Enrollees

Front 23

A system designated to determine the medical necessity an appropriateness ok medical service or procedure is

Back 23

Utilization review

Front 24

A multi-specialty practice in which health care services are provided within the building complex old by the hill maintenance organization HMO is referred to as

Back 24

Staff model

Front 25

Members of a PPO normally do not have to choose

Back 25

Primary care provider

Front 26

The document on which patients charges and payments are recorded is

Back 26

ledger card

Front 27

The most common format used to computer text files in on internet if a

Back 27

ASCII American Standard Code for Information Interchange

Front 28

The primary objective in submitting claims is

Back 28

submit clean claim

Front 29

Which organizations are responsible for creating revised CMS 1500

Back 29

NUCC/NUBC

Front 30

OCR works best with original copies using

Back 30

Mon space fonts

Front 31

What are the specific guidelines for OCR scan able claims

Back 31

Using upper case letters, using eight-digit birth date format , using no dollar signs or decimal point

Front 32

Indentify an important advantage of filing claims electronically

Back 32

It reduces rain birth month

Front 33

Under what circumstances is a claim attachment

Back 33

When an unlisted procedure code is reported