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60 terms

chp 3,4,7

moa140
STUDY
PLAY
most legal issues of private health insurance claims fall under
civil law
when does the physician/patient contract begin?
when the physician accepts the patient and agrees to treat the patient
most physician/patient contracts are
implied
when a patient carries privatemedical insuranc, the contract for treatment exist between
the physician and the patient
who does the contract exist between in a worker' compensation case?
the physician and the insurance company
the insured is always
the individual enrollee or organization protected ( work)
the reason for a condination of benefites statement is a health insurance policy is
to prevent duplication or pverlappimg of pymts for the same medical expense
Mr. Talili has two medical insurance policies.to prevent duplication of payment for the same medical expense, the policies include a
condition of benefits statement
when a medical facility is sent correct reimbursment from a insurance company for professional services, the sites receives
all the above:
the indemnity
the payment
the check
if a child has health insurance coverage from two parents, aconding to the birthday law
the health plan of the person whos bday ( month and day) falls earlier in the calendar year will pay first
acconding with the bday law, if both the mother and the father have the same bday
the plan of the person who has cover longer is the primery payer
conditions that existed and were treated before the health insurance policy was issued and called
prexisting
an attachment to an insurance policy that excludes certain illlinesses or disabilities that would otherwise be covered is referred to as a/an
exclusion
what is the correct term to used to determine if a procedure is covered and demically necessary?
preauthorization
Mrs. Thompsett leaves her place of employment. she is eligible to reansfer her medical insurance coverage from a gropu to an induvidual contract. this is know as
conversion privilage
why would conversion from a griopu policy to an individual policy be advantageous?
no physician examination required
Mr. Ott laid laid off from his job. he is protected by COBRA which requires his employer to
extend group health insurance coverage for 18 months
the act created to protect workers and their families so that they can get maintain health insurance if they change or lose their jobs is called the
consolidated omnibus budget reconciliation act ( COBRA)
a type of managed care organization created by the 1982 Tax Equality and Fiscal responsibility act (TEFRA) that allows for enrollemnt of medicare beneficiaries into managed care plans is a/an
comperirive medical plan (CMP)
a state and federal program for chindrens who are younger than 21 years of age and have special heatlh care need is
maternal and child heatlh programns (MCHP)
Assigment of benefits is
the transfer of one of legar right to collect the amount payable under an unsurance contract
a ecounter form may also be know as a
patient service slip
the source documets for insurance claims data is the
superbill
a daily record sheet used to record daily business transactions is called a /an
day sheet
it is advisable to process insurance claims
in batches, grouping claims of patients who have the same ty[e of insurance
an insurance claims register facilites
follow up insurance claims
when the physician services have been submitted to the patient's insurance company by the physician's office, the patient should
be send a monthly statements indicating the insurance company has been billed
a health record is considered
medical information
medical record
BOTH A AND B
a medical report is a
permanet legal document
part of the health record
both a and c
the key to substant procedure and idagnostic code selections for proper reimbursement is
supporting documentation on the health record
reasons for documentation are
defence to a professional liability claim
insurance carries require accurate documentation that supports procedure and diagnostic codes
BOTH A AND B
the SOAP in a patient medica record charting may be define as
Sunbjective, Objective, Assasekent Plan
when a patient fails to return for needed treatment, documentation should be made
in the patient medical record
in the appoiment book
on the financial record or ledger card
ALL THE ABOVE
how sould an entry a patien's medical record be corrected
cross out the incorrect entry, substitute the correct information, date and initial
a concise statement describing the symptoms, problems, condition, diagnosis physician-recommended return, or other factor that is the reason for the encounter is abbreviated
CC
levels of evaluation and management services are based on type(s) of physical examination that may be
problem focused
an expanded problem-focused examination is a/an
limited examinaation of single organ or system
the official american hospital association policy states that "abbreviations should be totally eliminated from the more vital sections of the record, such as the "
discharge summaries
a diseased condition or state is know as
mortality
what does comorbidirty mean?
uderlying diseases or other conditions present att the time of the visit
a new patient is one who
has not received any professional service with the physician witing the past 3 years
an stablished patient is one who
has previously received professional service from a physician or another physician of the same specialtly who belongs to the group practice within the past 3 years
in dealing with manages care plans, a referral is
the transfer or the total or specific care of a patient from one phyician to another
the term used when requesting an authorization for the patient to receive services elsewhere
BOTH B AND C
when a discossion takes place with a patient concerning the risjs and benefits of treatment option, it is considered
counseling
parts of the small and large intestines, right ovary, right uterine tube, appendix and right uterer are found in the
right lower quadrant
repair of lacerations that require layered closure of one or more or more of the deeper layer of skin and tissues is known as
intermediate
the code to repair a superficial laceration is found in the CPT intergumentary/surgery sectoion
simple
once an individual has been found guilty of committing a medicare or medical program-related crime,
exclusion from the program participation is mandatory
who may acept a subpoena
the person prospectice witness
and autorized person
BOTH A AND B
records that must be retained indefinitely include
patients medical records, xray films, and inactive patients medical records
the health insurance claims (CMS-1500) is know as the
universal claim form
an insurance claim form that contains no staples or highlighted areas and on which the bar code are has not been deformed is called
a physical clean claim
an insurance claim submitted with erros is referred to as
a dirty claim
what is the protocol to follow on receiving request for an attending ohysician statements from an insurance company on a patient who has applied for health insurance
request a fee form the insurance company before sending the attending physical statement
if you received, a request, accomopainedwith the correct autorization, asking to substract medical information from a patient medica record,
send only the information requested
office visits may be grouped on the insurance claims form if each visit
is consecutive and uses the same procedure code
OCR is the acromym for
optical character recognition
OCR guidelines for the CMS-1500 claim form state
it should not be fotocopied by the physician office to save an expenseve of nuying huge quantities
how should blocks be treated on an OCR CMS-1500 claim form that does not need any information?
leave the block blank
the CMS-1500 claim form is divided into which of the following major sections?
patient and physician information