Medical Billing and coding - insurance terms Flashcards

1619032040	Assignments of benefits	Reimbursement is directly sent from the payer to the provider	0
1619032041	Accept assignment	The provider agrees to accept what the insurance company approves as payment in full for the claim	1
1619032042	New patient	Us one who has not received professional service from the physician or other physician of the same specialty in the same group within the past three years	2
1619032043	Established patient	One who received professional service from the physician or another physician of the same specialty in the same group within the past three years	3
1619032044	Inpatient	Term used when a patient is admitted to the hospital with the expectations that the patient will stay for a period of 24 hours or more	4
1619032045	Outpatient	Patient who receives treatment in any of the following seethings • physicians office • hospital clinic, emergency department, hospital same-day surgery unit, ambulatory surgical center ( patient is released within 23 hours ) • hospital admission for observation	5
1619032046	Consultation	Is a service performed by a physician whose opinion or advice is requested by another physician in the evaluation or treatment of a patients illness or suspected problem	6
1619032047	Fee-for-service	A charged for each procedure or service performed by the physician. This is obtained from a *** schedule, which is a list of charges or allowance that have accepted for specific medical services.	7
1619032048	Fiscal intermediary	Is an insurance company that bids for a contract with CMS to handle the Medicare program in a specific area	8
1619032049	Explanation of benefits (EOB)	Describes the services billed and includes a breakdown of how the payment is determines	9
1619032050	Premium	Cost of insurance coverage paid annually, semi-annually or monthly to keep a policy in effect	10
1619032051	Deductible	Is a cumulative out-of-pocket amount that must be paid annually by the policyholder before benefits will be paid by the insurance company	11
1619032052	Co-payment	Cost sharing requirement for the insured to pay at the time of service. This is usually a specific dollar amount	12
1619032053	Coinsurance	A percentage of the cost of covered services that a policyholder or a secondary insurance pays. (Common payment 80/20, which indicates that 20% is the coinsurance for which the beneficiary or secondary insurance is responsible	13
1619032054	Coding	Process of converting diagnosis, procedures, and services into numeric and alphanumeric characters	14
1619032055	Medical necessity	Defined by Medicare as "the determination that a service or procedure renders is reasonable and necessary for the diagnosis or treatment of an illness or injury"	15
1619032056	Exclusion and limitations	Conditions, situations, and services not covered by the insurance carrier	16
1619032057	Pre-certification	To determine coverage for a specific treatment such as surgery, hospitalization or test, under the insured's policy	17
1619032058	Pre-determination	Determine the patients benefits and the maximum dollar amount that the insurance company will pay. First step, verification is completed prior to first visit	18
1619032059	Pre-authorization	Requirement for some health plan to obtain permission for a service or procedure before it is done. Indicates that a specific procedure or service is deemed "medically necessary"	19
1619032060	Qualified diagnosis	A working diagnosis which is not yet established	20
1619032061	Eligibility	Qualifying factor or factors that must be met before a patient receives benefits	21
1619032062	Coordination of benefits (COB)	When two insurance companies work together to coordinate payment of benefits	22
1619032063	Encounter form	Is also called a superb ill. It's a listing of diagnosis, procedures, and charges for a patient's visit	23
1619032064	Itemized statement	A statement of the patients account history, showing dates of service, detailed charges, payments ( i.e. deductibles and co-pays) the date the insurance claim was submitted, applicable adjustment and account balance	24
1619032065	Peer review organization (PRO)	A state group of physicians working under government guidelines to review cases and determine their appropriateness and quality of professional care	25
1619032066	Health insurance portability and accountability act (HIPAA)	Deals with prevention of healthcare fraud and abuse of patients on Medicare and Medicaid	26
1619032067	Civil monetary penalties law (CMPL)	Law passed by the federal government to prosecute cases of Medicaid fraud	27
1619032068	The Good Samaritan act	Developed to protect healthcare professionals from liability of any civil damages as a result of rendering emergency care	28
1619032069	Remittance advice	Is an electronic or paper-based report of payments sent by the payer to the provider	29
1619032070	The patient care partnership (Patients Bill of Rights)	Was developed to promote the interest and well being of the patients and residents of the healthcare facility. This bill has still not become law	30