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the patient is not responsible for paying what the insurance plan denies

If the insurance plan has a hold harmless clause; it means

make certain they are on mailing lists to recieve newsletters from third-party payers; remain current on news released by the CMS; stay current with the DHHS updates. All of the above

To remain up-to-date with the frequent changes of health insurance processing, health insurance specialists should:


The process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim is called:

facilitate analysis of the practice's patient base for improvement and efficiency and communicate diagnostic and treatment data to insurance plans for maximum recovery of benefits.

Accurate coding of diagnoses, procedures, and services rendered to the patient allows a medical practice to:

American Medical Association

Which of the following is not a professional association for health insurance specialists?


If preauthorization for treatment by specialists and post-treatment reports were not filed, the claim would be:

reimbursement specialist

Another name for health insurance specialist is:

practice's patient data base; number of claims requirements and reimbursement regulations; time the office staff must devote to fulfilling contract requirements; all of the above

Each new provider-managed care contract increase the:


According to the occupational outlook handbook published by the U.S. Department of Labor-Bureau of Labor statisitics, health care facilities and insurance companies will hire insurance specialists at an increased rate per year of:

Diagnosis coding and medical necessity

What involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity of performing that procedure of service?

electronic claims processing

Providers who send data in a standardized machine-readable format to an insurance company via disk, telephone modem, or cable are implementing:

International Classification of Diseases-Ninth Revision, Clinical Modification

ICD-9-CM stands for:

Current Procedural Terminology

What does CPT stand for?

American Medical Association

The CPT manual is published by the?

attention to details; strong sense of ethics; ability to work independently; all of the above

A successful health insurance specialist should have which of the following characteristics:


Prior approval

Hold harmless clause

Patient not responsible for paying what the plan denies

health care provider


Electronic Data Interchange

Exchange of data between provider and insurance company


Diagnostic codes


HCPCS level 1 codes


Principles of right or good conduct


Results of processing a claim sent to patient

Remittance advice

Provider's notification regarding payment of claim

Respondeat superior

Physician's legal responsibility for actions of employees


Certified Professional coder

Medical malpractice insurance

Liability insurance for providers

Professional liability insurance

Errors and omissions insurance

HCPCS level II codes

National codes


Reporting diagnoses, procedures, and services

review health-related claims for accuracy; determine medical necessity for procedures or services performed; refer claim to an investigator for a more thorough review; check patient's current eligibility and benenfit status at each office visit; assign codes to diagnoses and procedures; process claims for reimbursement

List some of the job duties performed by a health insurance specialist

a health care facility(or physician) that employs health insurance specialists is legally responsible for employees' actions performed with in the context of their employment

Explain what is meant by respondeat superior

medical malpractice insurance is a type of liability insurance which covers physicians and other health care professionals for liability as to claims arising from patient treatment

Explain what medical malpractice insurance is and why it is important to physicians and other health care professionals

The American Academy of Professional Coders(AAPC); The American Health Information Management Association(AHIMA); The American Medical Billing Association(AMBA)

Name the three professional associations that offer credentials for health insurance specialists

Medical necessity involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity for performing that procedure or service

Explain what is meant by medical necessity and give an example

Providers send data in a standardized machine-readable format to an insurance company via disk, telephone modem, or cable

What is electronic claims processing

A mutual exchange of data between the provider and insurance company, often used by clearinghouses.

What is electronic data interchange?

Current procedural terminology(CPT) and HCPCS level II (national codes)

List the levels of the Healthcare Common Procedure Coding System

amount of control the hiring organization exerted over the worker's activities; responsibility for costs of operation(e.g. equipment and supplies); method and form of payment and benefits; length of job commitment made to the worker; nature of the occupation and skills required.

List the 5 ways to determine independent contractor status according to the common law "right to control" test

health insurance specialists are guided by a scope of practice, which defines the profession, delineates qualifications and responsibilities, and clarifies supervision requirements

What is meant by scope of practice?

Bonding; liability; property; workers' compensation.

List the four types of insurance that health care providers and facilities typically purchase to cover their employees

Preauthorization, or prior approval for treatment by specialists, is important because if the requirements are not met, the payment for the claim will be denied.

Why is perauthorization important?

a hold harmless clause means that the patient is not responsible for what the insurance plan denies. The health care provider can not collect the fees from the patient

Explain what is meant by a hold harmless clause

Coding is the process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim

Describe what is meant by coding

The International Classification of Disease, Ninth Revision, Clinical Modification(ICD-9-CM) is the coding system used to report diagnoses and resons for encounters on physician office claims

Explain what the ICD-9-CM manual is

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