HIM 180 EXAM 3
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Created by:
the2022851 on December 10, 2011
Description:
Exam 3 HIM 180 Section 14169 - Phoenix College
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29 terms
Terms | Definitions |
|---|---|
 Outpatient care | Medicare Part B will only pay for |
| not medically necessary | Even if it is preapproved, a medical treatment may be denied reimbursement if it is |
| October 1 to September 30 | Medicare's fiscal year |
| Medigap | A specialized supplemental insurance policy devised for the Medicare beneficiary that covers the deductible and copayments typically not covered under the main Medicare policy, written by a nongovernmental third party payer |
| Participating Physician | A physician who contracts with an HMO or other insurance company to provide services and who has agreed to accept a plan's payment for services to subscribers |
| Automobile Insurance Carrier | When a Medicare patient is injured in an automobile accident and the car is covered by liability isnurance, the insurance claim is sent to the |
| Premium | In the Medicare program, the monthly fee that enrollees pay for Medicare Part B medical insurance |
| Prescribed Drugs | Medicare Part D would only pay for |
| Fiscal Intermediary | An organization under contract to the government that handles claims under Medicare Part A |
| Time Limit for Filing A Claim | The end of the calendar year after the fiscal year when services are furnished |
| Gatekeeper | A physician who controls patient access to specialists and diagnostics testing services is called a |
| True | Accurate and complete medical records are imperative for an HMO to retain eligibility |
| deposit the check | If Medicare overpays a reimbursement, you should |
| Second | When a Medicaid patient has Medicare, TRICARE or CHAMPVA, Medicaid should be billed |
| True | Congress passed an Act which requires most employers to offer an HMO alternative plan to their employees |
| Carve Outs | Medical services not included in the contract benefits |
| True | Medicaid is not an insurance program, it is an assistance program |
| False | If a physician disagrees with a Medicare payment, a review cannot be requested |
| October 1 to September 30 | Medicaid's fiscal year |
| Copayment | Portion that a patient pays EVERY TIME benefits are received throughout a year |
| Medicaid | Categorically Needy and Medically Needy are terms used with which health care reimbursement program |
| Amount Approved | A fee that Medicare decides the medical service is worth, which may or may not be the same as the actual amount billed |
| False | Medicare benefits automatically begin when an individual reaches retirement age |
| Remittance Advice | The document detailing services billed and describing payment determinations issued to providers of the Medicare and Medicaid programs |
| True | An eligible individual can refuse to participate in Medicare Part B |
| Capitation | A system of payment used by managed care plans in which physicians and hospitals are paid a fixed amount for each patient enrolled over a stated period of time, regardless of the type and number of services provided |
| True | Because the federal government sets minimum requirements, states are free to enhance the Medicaid program |
| Quality Improvement Organization | An organization of licensed doctors of medicine or osteopathy actively engaged in the practice of medicine or surgery, who evaluate other physicians about quality of professional care, as well as other factors according to federal guidelines. |
| False | Medicaid is administered by the Federal government with partial funding by the state government |
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