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Exam 3 HIM 180 Section 14169 - Phoenix College

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


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


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


A physician who controls patient access to specialists and diagnostics testing services is called a


Accurate and complete medical records are imperative for an HMO to retain eligibility

deposit the check

If Medicare overpays a reimbursement, you should


When a Medicaid patient has Medicare, TRICARE or CHAMPVA, Medicaid should be billed


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


Medicaid is not an insurance program, it is an assistance program


If a physician disagrees with a Medicare payment, a review cannot be requested

October 1 to September 30

Medicaid's fiscal year


Portion that a patient pays EVERY TIME benefits are received throughout a year


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


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


An eligible individual can refuse to participate in Medicare Part B


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


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.


Medicaid is administered by the Federal government with partial funding by the state government

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