Terms

5 Written Questions

1. The authorized signature of the pt for payment to be paid directly to the physician for services.
2. The person who has been insured, and insurance policy holder.
3. Coding system published by the american medical association that translates services received by a pt into a numeric value for convenience and continiuity of reporting these services to third parties for payment. The system is recognized by governmental payers and private insurance companies. (*always 5 digits ex:25000)
4. The total amt. owed by the practice to suppliers and other service providers.
5. A printed form with the pt's charges and the amt. paid for the servces rendered, which the pt takes with her. (receipt)

5 Matching Questions

1. Preferred Provider Organization (PPO)
2. Coodination of Benefits (COB)
3. Utilization Management
4. Precertification
5. Group Insurance

1. a Procedures used by insurers to avoid ducplication of payment on claims when the pt has more than one policy. one insurance becomes the primary payer and no more than 100% of the costs are covered.
2. b A panel that tracks what their members receive and checks if their medical care meets the standards of the organization.
3. c Insurance offered to all employees by and employer.
4. d This plan offers different insurance coverage depending on whether the pt receives services from a contracting network or non-network physician. The benefits are higher if the physician provider is a member of the PPO (or is a network physician).
5. e Prior authorization must be obtained before the pt is admitted to the hospital or some specified outpatient or in-office procedures.

5 Multiple Choice Questions

1. The standard claim form
   1. Coding
   2. Medicaid
   3. Claim
   4. CMS 1500
2. Established in 1973 for the spouses and dependent children of veterans who have total, permanent, service-connected disabilities.
   1. Health Maintenance Organization (HMO)
   2. Preferred Provider Organization (PPO)
   3. Civilian Health and Medical Program of the Veterans' Administration (CHAMPVA)
   4. TRICARE-Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
3. A specified amt. that the insured must pay toward the charge for professional services rendered.
   1. Individual Insurance
   2. Group Insurance
   3. Copayment or Coinsurance
   4. Accounts Receivable
4. A physician who has contacted to participate with an insurance company to be reimbursed for services according to the company's plan.
   1. Member Physician
   2. Admitting Physician
   3. Attending Physician
   4. Precertification
5. A list of approved professional services for which the insurance company will pay with the maximum fee paid for each service.
   1. Coding
   2. Fee Schedule
   3. Medicaid
   4. Deductible

5 True/False Questions

1. Claim → Transference of words into numbers to facilitate the use of computers in claim processing.

   True        False

2. Capitation → The health care provider is automatically paid a fixed amt. per month regardless of provided services for each pt who is a member of a particular insurance organization.

   True        False

3. Attending Physician → The physician who cares for a pt in the hospital (not necessarily the physician who admitted the pt)

   True        False

4. Explanation of Benefits (EOB) → A printed description of the benefits provided by the insurer to the beneficiary.

   True        False

5. Medicaid → A predetermined amt. that the insured must pay each year before the insurance company will pay for an accident of illness.

   True        False