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;
59 Cards in this Set
- Front
- Back
Fee-for-service
|
payment arrangements that outline, in a written fee schedule, exactly how much money the insurance carrier will pay the physician for each treatment and/or service provided
|
|
Gatekeeper
|
A physician, typically a practitioner or an internest, who serves as the primary care physician for an individual
|
|
HMO
|
type of health insurance that uses a PCP also known as a gatekeeper to manage health care services for an individual
|
|
Managed Care
|
type of health insurance coverage that controls the care of each subscriber by using a PCP as a central health care supervisor
|
|
POS
Point of service |
a type of insurance plan that allows a HMO enrollee to choose his or her own non member physician at a lower benefit rate, costing the patient more money out of pocket
|
|
PPO
Preferred Provider Organization |
a type of health insurance coverage in which physicians provide health care services to members of the plan at a discount
|
|
Third party payer
|
an individual or organization not directly involved in an encounter but connected to it through an obligation to pay for that encounter
|
|
UCR
Usual Customary Reasonable |
a formula used by insurers to determine the fee to be paid for a particular treatment or service
|
|
Copay
|
a fixed amount of money that an individual pays for each visit to a health care provider
|
|
Deductible
|
the amount of money patients must pay, out of their own pockets, before insurance benefits begin
|
|
Disclosure
|
as defined by HIPAA, the sharing of information by health care professionals to anyone outside of their facility
|
|
HIPAA
|
-Health Insurance Portability and Accountability Act
-legislation that secures patients information so it is available to those who should see it, while protecting that information from those who should not |
|
PHI
|
-Protected Health Information
-any identifiable patient health information, regardless of the form in which it is stored |
|
Use
|
the sharing of information between people working in the same health care facility for purposes of caring for a patient
|
|
Accept assignment
|
the process whereby a policyholder gives permission to the insurer to pay benefits directly to the provider
|
|
Birthday rule
|
the rule used to establish the primary insurance policy for a child by determining which parent has a birthday closest to January 1
|
|
Eligibility confirmation
|
The process of contacting an insurance carrier to confirm that an individual is qualified for benefits to pay for services provided by a health care professional on a given day
|
|
Encounter form/Superbill
|
the form that documents what occurred during a meeting between a patient and a health care provider
|
|
Policy holder
|
also called the insured, the person who brings the insurance policy to the family
|
|
Responsible party/guarantor
|
the person who will pay any money due to a health care provider that is not paid by the insurance company
|
|
Verification
|
contacting an insurance carrier to confirm that an individual has current, valid health insurance coverage
|
|
Abstracting
|
Pulling out keywords
|
|
Coding for coverage
|
to change a code to fit what the insurance company will pay for
|
|
CPT
|
Current Procedural Terminology
|
|
Diagnosis
|
A physicians determination of a patient's condition, illness, or injury
|
|
ICD-9-CM
|
The International Classification of Diseases-9th Revision-Clinical Modification
|
|
Mutually exclusive codes
|
2 or more codes that are identified in the coding book which cannot be used on the same claim form
|
|
Procedure
|
A treatment or service provided by a health care professional
|
|
Query
|
to ask
|
|
Unbundling
|
Coding individual parts of a specific procedure, rather than one combo code that includes all of the components
|
|
Upcoding
|
using a code on a claim form indicating a higher level of service than that which was actually performed
|
|
Adverse reaction
|
harm or danger to an individual caused by interaction with a drug or chemical
|
|
Condition
|
The presenting situation, such as infection, fracture, or wound
|
|
Eponym
|
the name of a condition derived from the name of a person
|
|
E code
|
a code that explains how an injury or a poisoning happened, and/or where it happened
|
|
V code
|
a code to describe an encounter between a provider and an individual w/o a specific current health condition
|
|
Manifestation
|
a condition caused by or developed from the existence of another condition similar to a side effect
|
|
Neoplasm
|
abnormal tissue, also defined as a growth or tumor
|
|
Underlying condition
|
a disease that affects or encourages another condition
|
|
Etiology
|
The identification of the cause of a disease
|
|
Morbidity
|
the study of disease and the causes of disease in a given population or society
|
|
Mortality
|
the proportion of deaths to the population as a whole, also known as death rate
|
|
Established patient
|
a person who has received professional services from a particular provider within the past 3 years
|
|
E/M
3 key components |
Evaluation and Management
1. Relationship 2. Location 3. Complexity/Time |
|
Modifier
|
a code added to a CPT code to provide more detail or an explanation of an unusual circumstance affecting a service
|
|
New patient
|
A patient who has not received any professional services within the past 3 years from this provider
|
|
Radiology
|
x-rays, nuclear medicine, and diagnostic ultrasound
|
|
Surgery
|
Operative or surgical procedures
|
|
Code linkage
|
the process of directly connecting each procedure code to at least one diagnosis code on the insurance claim form
|
|
Place of service
|
a 2 digit code that categorizes the location where the procedure was performed
|
|
Type of service
|
A 1 or 2 digit code that categorizes the procedure performed
|
|
tracer
|
an official request for a third party payer to search its system for a missing health claim form
|
|
EOB
|
Explanation of Benefits
|
|
allowed amount
|
the maximum payment for service or treatment from an insurance carrier
|
|
EFT
|
Electronic Funds Transfer
money that is moved from one bank account to another bank account via computer |
|
Payee
|
an individual or organization that receives payment from another individual or organization
|
|
Payer (payor)
|
an individual or organization that sends payment to another individual or organization
|
|
Balance billing
|
The invoicing of a patient for the difference between the allowed amount and the physician's charge
|
|
Remittance
|
Payment for services provided
|