assignment of benefits
The authorized signature of the patient for payment to be paid directly to the physician for services
a pre-determined amount that the insured must pay each year before the insurance company will pay for an accident or illness
a system of medial team members and groups who provide quality and cost effective care that encompasses both healthcare delivery and payment for services
established to aid dependents of active service personnel, retired service personnel and their dependents, and dependents of service personnel who died on active duty wth a supplement for medical care in military of Public Health Service facilities
a joint funding program by federal and state governments (excluding AZ) for low income patients on public assistance for their medical care
To determine a code, the name of the procedure or service that most accurately identifies the service performed is selected. You are looking in this book?
Established for the spouses and dependent children of veterens who have total, permanent, service connected disabilities
a primary care physician who coordinates the patient's hosptial admissions, care received from specialists and so on
Prior authorization for hosptial admission and some outpatient and in-office procedures
correctly and completely
A coding rule: code ____ and ____ any diagnosis or procedure that affects the care, influences the health status, or is a reason for treatment on that visit
coordination of benefits COB
Procedures used by insurers to avoid duplication of payment on claims when the patient has more than one policy
independent practice association IPAs
Type of HMO that is composed of individual health care providers joined together to provide prepaid healthcare to groups and individuals
copayment or co-insurance
a specified amount that the insured must pay toward the charge for professional services rendered
health maintenance organization HMO
a prepaid group practice serving a specific geographic area with a wide range of comprehensive health care at a fixed fee schedule
consent to release of information to the ins company
You must have patient's signature before processing a claim...why?
follow up by calling the insurance company
If you have filed a claim and have not received payemnt or a denial, you should do this
in a managed care delivery system, this person is responsible for coordinating all care for the patient
a printed form containing a list of the services with corresponding codes (encounter form)
wrong pt ID number, claim suspended additional info, wrong ICD9 code
Some reasons for delays in payment
patient is primary and spouse is secondary
A husband and wife both have insurance coverage that overlaps through their employers. The wife comes in to be seen. This insurance is considered her primary.
social and alpha character
a Medicare patient's health insurance claim number is comprised of these?
shorter turn around time, decreased prep time
what are the advantages of processing claims electronically?
a review by allied health professionals at predetermined times to assess the necessity of the patient remaining in an acute care facility
this insurance allows patients to choose their provider and see specialists without referrals?
businesses with less than 10 FT employees including phys
The only practitioners that can currently bill Medicare with the hard copy of CMS-1500 form are?
If information is given to a third party without the signed authorization of the patient, the one who gave the information may be charged with breach of this?
workers compensation WC
a government program that provides insurance coverage for people injured on the job or who have developed work-related disorders, disabilities, or illnesses
these plans integrate the financing and appropriate delivery of services to covered persons by contracting providers for comprehensive health care services, with specific standards for the providers' specialty, and maintaining programs for quality assurance and utilization review.
Usually, the physician agrees to treat people enrolled in the program for an agreed this?
workers compensation WC
Employees in the US have the benefits of being covered by these laws if injured while working or becoming ill as a result of work.
the two standard non-menclature code books (ICD and CPT) are published this often and are absolutely essential to the function of the medical office
med care, temp disability, perm disability, family pay fatal injury
Four types of benefits under WC
-pt can be seen in our out of hospital for med care
-temporary disability, week or monthly cash benefits and med care
-perminant disability, cash benefits and med care possible lump sum
-family member pay if fatal injury
birthday rule, according to parents birthday first on calander year
When a child is covered by two insurance policies (one from each parent) you follow this rule (explain it as well)
These type of insurance plans usually have deductibles and copayment requirements and the office usually files claims for services rendered?
HMO takes the place of traditional
If a patient has a Medicare HMO they cannot also have traditional Medicare. Why?
non covered charge or service
physicians only have to notify Medicare patients of charges for this reason?
history, exam, medical decision, counseling, coordination of care, nature of presenting problem, time spent
what are the 7 components used in defining the levels of e/m services?