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key terms

Compliance is the process of

Metting regulations, recommendations, and expectations of federal and state agencies that pay for healthcare services and regulate the industry.

(eHIM) electronic Health Information Management

Transactions in wich health care information is accessed, processed, stored, and transferred using electronic technologies

Baby Nelson was born on January 20, 2005, at 7:15 AM. When using the required Health Level 7 (HL7) format for transmission, how would this appear


An independent organization that receives insurance claims from the physician's office, performs edits, and transmits claims to insurance carriers is known


Under HIPAA guidelines, a healthcare coverage carrier, such as Blue Cross/Blue Shield that transmits health information in electronic form in connection with a transaction is called

covered entity

Dr. John Doe contracts with an outside billing company to manage claims and accounts receivable. Under HIPAA guidelines, the billing company is considered a ________of the provider

business associate

An individual designated to assist the provider by putting compliance policies and procedures in place and training office staff is known as a/an _________________ under HIPAA guidelines.

privacy officer or privacy official

If you give, release, or transfer information to another entity, this is known as


Define protected health information (PHI).

Data that identifies an individual and describes his or her health status, age, sex, ethnicity, or other demographic characteristics, whether or not that information is stored or transmitted electronically.

Unauthorized release of a patient's health information is called

breach of confidential communication

A confidential communication related to the patient's treatment and progress that may be disclosed only with the patient's permission is

privileged communication

Under HIPAA, exceptions to the right of privacy are those records involving

a. Patients who are members of a managed care organization (MCO and the contract allows the MCO access to their medical records for quality care and utlization management purposes)
b. Communicable diseases
c. Medical device that breaks or malfunctions and the Food and Drug Administration requires providers to report certain information
d. Criminal investigations or assist in locating a missing person, material witness, or suspect, and police have the right to request certain informatio e. Subpoenaed records or search warrants
f. Patient that is suing someone and wants to protect himself or herself
g. Suspicious death or suspected crime victim
h. Workers' compensation (industrial accident) cases and physician is employed by a third party (insurance company)
i. Child abuse, elder abuse, domestic violence or gunshot wounds

Under the False Claims Act, billing a claim for services not medically necessary.


Changing a figure on an insurance claim form to get increased payment.


Dismissing the copayment owed by a Medicare patient.


Neglecting to refund an overpayment to the patient.


Billing for a complex fracture when the patient suffered a simple break.


Enforcement of the privacy standards of HIPAA is the responsibility of

Office for Civil Rights (OCR)

Verbal or written agreement that gives approval to some action, situation, or statement is called


An individual's formal written permission to use or disclose his or her personally identifiable health information for purposes other than treatment, payment or healthcare operations is called


Individually identifiable health information (IIHI) is any part of a person's health data (e.g., demographic information, address, date of birth) obtained from the patient that is created or received by a covered entity


HIPAA requirements protect disclosure of protected health information outside of the organization but not for internal use of health information.


Under HIPAA, patients may request confidential communications and may restrict certain disclosures of protected health information.


A national provider identifier (NPI) number is issued for five years and must be renewed


To submit an insurance claim for medical services that were not medically necessary is a violation of the False Claims Act (FCA)


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