Insurance Handbook For The Medical Office

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Chapter -3 1-26

A/an_______ is a legally enforceable agreenent or contract.

insurance contract policy

An individual promising to pay for medical services rendered is known as a/an

guarantor or subcriber

List five health insureance policy renewal provisions.

a. Canceable
b. Optionally renewable
c.Condtionally renewable
d.Guaranteed renewable
e. Noncancelable

Insurance reimbursement or payment is also called

Indemnity

Name two general health insurance policy limitations

a. exclusions
b. waiver or rider

THe act of determining whether treatment is covered under an individual's health insurance policy is called

precertification

The procedure to obtain permission for a procedure before it is done, to determine whether the insureance program agrees it is medically necessary, is termed

preauthorization

Determining the maxium dollar amount the insureance company will pay for procedure before it is is known as

predetermination

Name three way an individual may obtain health insurance.

a. take out insurance through a group plan (contract or policy)
b. pay the premium on an individual basis.
c. enroll in a prepaid health plan

List four methods a physician's practice may use to submit insureance claims to insurance companies.

a. manual cliams submission on thr revised CMS 1500 form
b. electronic cliams transmitted form in office computer
c. contracting with an outside service bureu to prepare and transmit electroinc claims on behalf of the health care provider offices.
d. direct data entry into the payers system

A document signed by the insured directing the insurance company to pay benefits directly to the physician is known as a/an

assignment of benefits

A patients services slip personalized to the practice of the physican and used as a communications/billing tool during routing of the patients is also know as a/an

a.encounter
b. transaction slip
c. charge slip
d. fee ticket

For electronic access to computer data, computerized signatures may consist of the following verfication or access methods.

a. series of numbers
b.series of letters
c. electronic writing
d. voice
e. finger print transmission
f. computer key

Guidelines for avoding unauthorized use and preventing problems when a medical practice uses a facsimile signature stamp are

a. make oly one stamp
b. allow only long term trusted boned staff members to have access to the stamp
c. keep the stamp in a location with a secure look.
d. Limit access to the stamp

An insurance company takes into account benefits payable by another carrier in determing its own liability.

d. COB

Benefits paid by an insurance company to an insured person

g. indemnity

Transfer of one's right to collect an amount payable under an insurance contract.

b. assignment

Time that must elapse before an indemnity is paid

k. waiting period

Acts for insurance company or insured in settlement of claims

a. adjuster

periodic payment to keep insurance policy in force.

h. premium

Amount insured person must pay before policy will pay

e. deductible

Time period in which a claim must be filed

j. time limit

Certain illnesses or injuries in a policy that the insurance company will nto cover.

f. exclusion

Insurance company that carries the insurance

c. carrier

One who belongs to an insureance plan

i. subscriber

When a patient goes to a physician's office seeking medical services the physician accpets the patient and agrees to render treatment and both parties agree, this contract is know as a /an

c. implied contract

The process of checking and confirming that a patient is covered under an insureance plan is known as

b. eligibility verfication

A provision that allows the policyholder the right to refuse to renew the insurance policy on a premium due date is called

c. optionally renewable

A provision in a health insurance policy in which two insureance carries work together for payment so that there is no duplication of benefits paid between the primary insurance carrier and the secondary insurance carrier is called

c. COB

A type of tax free saving account that allows individuals and their employers to set aside money to pay for health care expenses is known as

d. all of the above

Time limit for filing insurance claims to commercial carrier may have a range of

b. 30 days form the date of service to 1 1/2 years

If a physician belongs to a preferred provider organzation (PPO) and not follow his or hers contract with PPO the paitent is liable for the bill

Flase

The birthday law is a change in the order of determination of coordination of benefits regarding primary and secondary insurance carries for dependent childern.

True

The consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) mandates that when an employee is laid off form a company the group health insurenace coverage must continue at group rates for up to 18 months.

True

Capitation is aytem od payment used by managed care plans in which a member physician is paid different amounts monthly for each patients enrolled.

Flase

A provider's signature on a CMS-1500 claim form is acceptable as a handwritten a facsimile stamp, or electronic signature.

True

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