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20 terms

Chapter 1

STUDY
PLAY
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