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The concept that every procedure or service reported to a third-party payer must be linked to a condition that justifies that procedure or service is called medical...

Necessity

The administrative agency responsible for establishing rules for Medicare claims processing is called the...

Centers for Medicare & Medicaid Services (CMS)

Documentation submitted to an insurance company requesting reimbursement for healthcare services provided is called a health insurance...

Claim

Which organization is responsible for administering the Certified Medical Reimbursement Specialist certification exam?

AMBA

Which clause is implemented if the requirements associated with preauthorization of a claim prior to payment are not met?

Hold Harmless

Data published in the Occupational Outlook Handbook indicate the job opportunities for health insurance specialists will increase by what percentage?

9% to 17%

Patients with health insurance may require _______ (prior approval) for treatment by specialists & documentation of post-treatment reports.

Preauthorization

The process of reporting diagnoses, procedures, & services as numeric & alphanumeric characters on an insurance claim is...

Coding

Which is another title for the health insurance specialist?

Reimbursement Specialist

If a patient is seen by a provider who orders a chest x-ray, which diagnosis should be linked with the procedure to prove medical necessity?

Shortness of Breath

The principles of right or good conduct are known as...

Ethics

The notice sent by the insurance company to the provider, which contains payment information about a claim, is the...

Remittance Advice

When an individual chooses to perform services for another under an express or implied agreement & is not subject to the other's control, the individual is defined as a(n)...

Independent Contractor

Employers are generally considered liable for the actions & omissions of employees as performed & committed within the scope of their employment. This is known as...

Respondeat Superior

Third-party payer _______ review CMS-1500 claims to determine whether the charges are reasonable for payment.

Claims Examiners

Which type of insurance should be purchased by health insurance specialist independent contractors?

Errors & Omissions

ICD codes are assigned to _______ on outpatient & physician office claims.

Diagnoses

A remittance advice contains...

Payment information about a claim

High blood pressure is an example of a...

Diagnosis

According to the Occupational Outlook Handbook, which setting offers the fastest employment growth & majority of new jobs for health information technicians (including those who perform insurance specialist functions)?

Physician offices

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