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29 terms

HIM 180 EXAM 3

Exam 3 HIM 180 Section 14169 - Phoenix College
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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