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Study sets matching "understanding health insurance"

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Study sets matching "understanding health insurance"

52 terms
UNDERSTANDING HEALTH INSURANCE CHAP 6
adverse effect
benign
carcinoma (Ca) in situ
comorbidity
taking less of a medication than is prescribed by a provider…
not cancerous
a malignant tumor that is localized, circumscribed, encapsula…
concurrent condition that coexists with the first-listed diag…
adverse effect
taking less of a medication than is prescribed by a provider…
benign
not cancerous
72 terms
UNDERSTANDING HEALTH INSURANCE CHAP 3
Accreditation
Adverse Selection
Amendment to the HMO Act of 1973
cafeteria plan
voluntary process that a health care facility or organization…
covering members who are sicker than the general population.
legislation that allowed federally qualified HMOs to permit m…
also called triple option plan; provides different health ben…
Accreditation
voluntary process that a health care facility or organization…
Adverse Selection
covering members who are sicker than the general population.
82 terms
UNDERSTANDING HEALTH INSURANCE CHAP 5
abuse
American Recovery and Reinvestment Act…
ANSI ASC X12N 837
authorization
actions inconsistent with accepted, sound medical, business,…
authorized an expenditure of $1.5 billion for grants for cons…
variable-length file format used to bill institutional, profe…
document that provides official instruction, such as the cust…
abuse
actions inconsistent with accepted, sound medical, business,…
American Recovery and Reinvestment Act…
authorized an expenditure of $1.5 billion for grants for cons…
66 terms
UNDERSTANDING HEALTH INSURANCE CHAP 4
accept assignment
accounts receivable
accounts receivable aging report
accounts receivable management
provider accepts as payment in full whatever is paid on the c…
the amount owed to a business for services or goods provided.
shows the status (by date) of outstanding claims from each pa…
assists providers in the collection of appropriate reimbursem…
accept assignment
provider accepts as payment in full whatever is paid on the c…
accounts receivable
the amount owed to a business for services or goods provided.
27 terms
UNDERSTANDING HEALTH INSURANCE CHAP 13
Away From Home Care Program
BCBS basic coverage
BCBS major medical (MM) coverage
BlueCard Program
provides continuous BCBS health care coverage for subscribers…
BlueCross BlueShield (BCBS) coverage for the following servic…
BCBS coverage for the following services, in addition to basi…
program that allows BCBS subscribers to receive local Blue Pl…
Away From Home Care Program
provides continuous BCBS health care coverage for subscribers…
BCBS basic coverage
BlueCross BlueShield (BCBS) coverage for the following servic…
21 terms
Understanding Health Insurance Chapter 12
Commercial Health Insurance
Fee-for-service (or indemnity) insurance
High Risk Pools
Managed care
covers the medical expenses of individuals (e.g., private hea…
Traditional health insurance that covers a portion of service…
Last resort health insurance for individuals who cannot obtai…
Health maintenance organization, preferred provider organizat…
Commercial Health Insurance
covers the medical expenses of individuals (e.g., private hea…
Fee-for-service (or indemnity) insurance
Traditional health insurance that covers a portion of service…
62 terms
UNDERSTANDING HEALTH INSURANCE CHAP 9
All-Patient diagnosis-related group (A…
All-Patient Refined diagnosis-related…
allowable charge
ambulance fee schedule
DRG system adapted for use by third-party payers to reimburse…
adopted by Medicare in 2008 to reimburse hospitals for inpati…
maximum fee a provider may charge.
payment system for ambulance services provided to Medicare be…
All-Patient diagnosis-related group (A…
DRG system adapted for use by third-party payers to reimburse…
All-Patient Refined diagnosis-related…
adopted by Medicare in 2008 to reimburse hospitals for inpati…
36 terms
UNDERSTANDING HEALTH INSURANCE CHAP 14
advance beneficiary notice of noncover…
benefit period (Medicare)
conditional primary payer status
coordinated care plan
document that acknowledges patient responsibility for payment…
begins with the first day of hospitalization and ends when th…
Medicare claim process that includes the following circumstan…
also called managed care plan; includes health maintenance or…
advance beneficiary notice of noncover…
document that acknowledges patient responsibility for payment…
benefit period (Medicare)
begins with the first day of hospitalization and ends when th…
10 terms
Understanding Health Insurance; Abbreviations
C.C
HPI
FH
SH
Chief complaint
History of present illness
Family history
Social history
C.C
Chief complaint
HPI
History of present illness
591 terms
Understanding Health Insurance
Health Insurance
Group Health Insurance
Personal Health Record (PHR)
Total Practice Management Software (TP…
A contract between a policyholder and a third-party payer or…
Traditional healthcare coverage subsidized by employers and o…
A web-based application that allows individuals to maintain a…
Used to generate the EMR, automating the following medical pr…
Health Insurance
A contract between a policyholder and a third-party payer or…
Group Health Insurance
Traditional healthcare coverage subsidized by employers and o…
69 terms
understanding health insurance
cms-1500
accept assignment
accounts receivable management
accounts receivable aging report
the insurance claim form used to report professional services
when the provider agrees to accept what the insurance company…
assists providers in the collection of appropriate reimbursem…
shows the status (by date) of outstanding claims from each pa…
cms-1500
the insurance claim form used to report professional services
accept assignment
when the provider agrees to accept what the insurance company…
50 terms
UNDERSTANDING Health Insurance
The document submitted to the payer re…
The Centers for Medicare and Medicaid…
A healthcare practioner is also called a
Which is the most appropriate response…
health insurance claim
Department of Health and Human Services
provider
Explain that the physician is with a patient, and ask if the…
The document submitted to the payer re…
health insurance claim
The Centers for Medicare and Medicaid…
Department of Health and Human Services
20 terms
Understanding Health Insurance Chapter 1&2
American Association of Medical Assist…
Centers for Medicare and Medicaid Serv…
Coinsurance
Fee Schedule
Enables medical assistant professional to enhance and demonst…
Administration agency within the federal Department of Health…
The percentage the patient pays for covered service after the…
List predetermine payments for health care services to provid…
American Association of Medical Assist…
Enables medical assistant professional to enhance and demonst…
Centers for Medicare and Medicaid Serv…
Administration agency within the federal Department of Health…
10 terms
UNDERSTANDING HEALTH INSURANCE CHAP 8
certificate of medical necessity (CMN)
durable medical equipment (DME)
durable medical equipment, prosthetics…
durable medical equipment, prosthetics…
prescription document for durable medical equipment, services…
canes, crutches, walkers, commode chairs, blood glucose monit…
defined by Medicare as equipment that can withstand repeated…
supply patients with durable medical equipment (DME) (e.g., c…
certificate of medical necessity (CMN)
prescription document for durable medical equipment, services…
durable medical equipment (DME)
canes, crutches, walkers, commode chairs, blood glucose monit…
20 terms
Understanding Health Insurance Chapter 3&4
Gatekeeper
Capitation
Primary care physician
Case Management
Primary care provider for essential health care services at t…
provider accepts pre-established payments for providing healt…
Responsible for supervising and coordinating health care serv…
Development of patient care plans to coordinate and provide c…
Gatekeeper
Primary care provider for essential health care services at t…
Capitation
provider accepts pre-established payments for providing healt…
30 terms
UNDERSTANDING HEALTH INSURANCE CHAP 16
beneficiary counseling and assistance…
beneficiary services representative (B…
catastrophic cap benefit
catchment area
individual available at a military treatment facility (MTF) t…
employed at a TRICARE Service Center; provides information ab…
protects TRICARE beneficiaries from devastating financial los…
the region defined by code boundaries within a 40-mile radius…
beneficiary counseling and assistance…
individual available at a military treatment facility (MTF) t…
beneficiary services representative (B…
employed at a TRICARE Service Center; provides information ab…
18 terms
UNDERSTANDING HEALTH INSURANCE CHAP 17
adjudication
arbitration
Energy Employees Occupational Illness…
Federal Black Lung Program
judicial dispute resolution process in which an appeals board…
dispute-resolution process in which a final determination is…
provides benefits to eligible employees and former employees…
enacted in 1969 as part of the Black Lung Benefits Act; provi…
adjudication
judicial dispute resolution process in which an appeals board…
arbitration
dispute-resolution process in which a final determination is…
8 terms
UNDERSTANDING HEALTH INSURANCE CHAP 12
automobile insurance policy
base period
commercial health insurance
disability insurance
contract between an individual and an insurance company where…
period of time that usually covers 12 months and is divided i…
covers the medical ex-penses of individuals groups; premiums…
reimbursement for income lost as a result of a temporary or p…
automobile insurance policy
contract between an individual and an insurance company where…
base period
period of time that usually covers 12 months and is divided i…
14 terms
UNDERSTANDING HEALTH INSURANCE CHAP 10
assessment
auditing process
local coverage determination (LCD)
local coverage determination (LCD)
contains the diagnostic statement and may include the provide…
review of patient records and CMS-1500 (or UB-04) claims to a…
formerly called local medical review policy (LMRP); Medicare…
formerly called local medical review policy (LMRP); Medicare…
assessment
contains the diagnostic statement and may include the provide…
auditing process
review of patient records and CMS-1500 (or UB-04) claims to a…
54 terms
UNDERSTANDING HEALTH INSURANCE CHAP 6
adverse effect
benign
carcinoma (Ca) in situ
comorbidity
taking less of a medication than is prescribed by a provider…
not cancerous
a malignant tumor that is localized, circumscribed, encapsula…
concurrent condition that coexists with the first-listed diag…
adverse effect
taking less of a medication than is prescribed by a provider…
benign
not cancerous
67 terms
UNDERSTANDING HEALTH INSURANCE CHAP 7
care plan oversight services
case management services
Category I codes
Category II codes
cover the provider's time supervising a complex and multidisc…
process by which an attending physician coordinates and super…
procedures/services identified by a five-digit CPT code and d…
optional performance measurement tracking codes that are assi…
care plan oversight services
cover the provider's time supervising a complex and multidisc…
case management services
process by which an attending physician coordinates and super…
68 terms
UNDERSTANDING HEALTH INSURANCE CHAP 4
accept assignment
accounts receivable
accounts receivable aging report
accounts receivable management
provider accepts as payment in full whatever is paid on the c…
the amount owed to a business for services or goods provided.
shows the status (by date) of outstanding claims from each pa…
assists providers in the collection of appropriate reimbursem…
accept assignment
provider accepts as payment in full whatever is paid on the c…
accounts receivable
the amount owed to a business for services or goods provided.
40 terms
understanding health insurance ch 15
In 1965
Medicaid
NOTE*
NOTE*
Congress passed Title 19 of the Social Security Act
Provides medical and health-related services to certain indiv…
To be eligible for federal funds, states are required to prov…
Each state administers its own Medicaid program, and CMS moni…
In 1965
Congress passed Title 19 of the Social Security Act
Medicaid
Provides medical and health-related services to certain indiv…
Understanding Health Insurance
prior to ACA, 83% of people in this co…
health insurance in the US came out of…
this lead to private insurance compani…
Blue Cross:
insured
Europe in the late 1800s and early 1900s
health insurance movement in Europe
the hospital based insurance plan; started at Baylor Universi…
prior to ACA, 83% of people in this co…
insured
health insurance in the US came out of…
Europe in the late 1800s and early 1900s
20 terms
Vocab for Understanding Health Insurance
Accept Assignment
Coordination of Benefits
Appeal
Claims Processing
provider accepts as payment in full what the insurance compan…
provisions in group health insurance policies that prevent mu…
documented as a letter; signed by the provider, explaining wh…
sorting claims upon submission to collect and verify informat…
Accept Assignment
provider accepts as payment in full what the insurance compan…
Coordination of Benefits
provisions in group health insurance policies that prevent mu…
UNDERSTANDING Health Insurance ch 1
The document submitted to the payer re…
The Centers for Medicare and Medicaid…
A healthcare practioner is also called a
Which is the most appropriate response…
health insurance claim
Department of Health and Human Services
provider
Explain that the physician is with a patient, and ask if the…
The document submitted to the payer re…
health insurance claim
The Centers for Medicare and Medicaid…
Department of Health and Human Services
87 terms
Understanding Health Insurance Chapter 7
Adjuvant Chemotherapy
Anesthesia time Unit
Appedix G
Appendix E
Chemotherapy administerd in addition to other cancer treatmen…
One 15-minute increment.
Summary of CPT codes that include moderate (conscious) sedati…
Codes exempt from modifier -51 reporting rules.
Adjuvant Chemotherapy
Chemotherapy administerd in addition to other cancer treatmen…
Anesthesia time Unit
One 15-minute increment.
39 terms
Understanding Health Insurance Chapter 6
Advance Beneficiary Notice (ABN)
Benign
Categories
Classification of Drugs by AHFS List
Acknowledges patient responsibility for payment if Medicare d…
Not cancerous
Printed in bold upper-and lowercase type and are preceded by…
Contains the American Hospital Formulary Services List number…
Advance Beneficiary Notice (ABN)
Acknowledges patient responsibility for payment if Medicare d…
Benign
Not cancerous
16 terms
Understanding health insurance
MEVS- allows providers to electronical…
Are medicaid patients ever required to…
Remittance advice
Dual Eligibles
Medicare Eligibility Verification System... MEVS can be accessed…
...
is sent to the provider which contains the current status of…
individuals entitled to Medicare and Medicaid . services cove…
MEVS- allows providers to electronical…
Medicare Eligibility Verification System... MEVS can be accessed…
Are medicaid patients ever required to…
...
81 terms
Understanding Health Insurance
American Association of Medical Assist…
Centers for Medicare and Medicaid Serv…
Coinsurance
Fee Schedule
Enables medical assistant professional to enhance and demonst…
Administration agency within the federal Department of Health…
The percentage the patient pays for covered service after the…
List predetermine payments for health care services to provid…
American Association of Medical Assist…
Enables medical assistant professional to enhance and demonst…
Centers for Medicare and Medicaid Serv…
Administration agency within the federal Department of Health…
207 terms
UNDERSTANDING HEALTH INSURANCE
POLICYHOLDER
INSURANCE CARRIER
GROUP INSURANCE
PERSONAL INSURANCE
A person who buys an insurance plan; the insured, subscriber,…
one who provides the benefits plan or a goverment program dev…
insurance that is purchased by a group (such as the employees…
An insurance plan issued to an individual. Premium rates are…
POLICYHOLDER
A person who buys an insurance plan; the insured, subscriber,…
INSURANCE CARRIER
one who provides the benefits plan or a goverment program dev…
20 terms
Understanding Health Insurance Vocabulary
Diagnosis pointer
Subjective
Objective
Assessment
Item letters A through L preprinted in Block 21 of the CMS-15…
Part of the note that contains the chief compliant and the pa…
Documentation of measurable of objective observations made du…
Contains the diagnostic statement and may include the provide…
Diagnosis pointer
Item letters A through L preprinted in Block 21 of the CMS-15…
Subjective
Part of the note that contains the chief compliant and the pa…
30 terms
Understanding Health Insurance
Accept Assignment
Financial Policy
Encounter Form
Primary Insurance
Participating physician's agreement to accept allowed charge…
Practice's rules governing payment from patients.
List of the diagnosis, procedures, and charges for a patients…
Health plan that pays benefits first.
Accept Assignment
Participating physician's agreement to accept allowed charge…
Financial Policy
Practice's rules governing payment from patients.
30 terms
understanding health insurance
coding
Health Care Provider
Preauthorization
Medical malpractice insurance
Process of reporting diagnoses, procedures, and services as n…
physician or other health care practitioner(e.g.,physicians a…
prior approval
a type of liability insurance that covers physicians and othe…
coding
Process of reporting diagnoses, procedures, and services as n…
Health Care Provider
physician or other health care practitioner(e.g.,physicians a…
69 terms
understanding health insurance
cms-1500
accept assignment
accounts receivable management
accounts receivable aging report
the insurance claim form used to report professional services
when the provider agrees to accept what the insurance company…
assists providers in the collection of appropriate reimbursem…
shows the status (by date) of outstanding claims from each pa…
cms-1500
the insurance claim form used to report professional services
accept assignment
when the provider agrees to accept what the insurance company…
20 terms
UNDERSTANDING HEALTH INSURANCE VOC
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN
THE PART OF THE NOTE THAT CONTAINS THE CHIEF COMPLAIN
DOCUMENTATION OF MEASURABLE OR OBJECTIVE OBSERVATIONS MADE DU…
CONTAINS THE DIAGNOSTIC STATEMENT AND MAY INCLUDE THE PROVIDE…
STATEMENT OF THE PHYSICIAN'S FUTURE PLANS FOR THE WORK-UP AND…
SUBJECTIVE
THE PART OF THE NOTE THAT CONTAINS THE CHIEF COMPLAIN
OBJECTIVE
DOCUMENTATION OF MEASURABLE OR OBJECTIVE OBSERVATIONS MADE DU…
60 terms
Understanding Health Insurance
The Inpatient Psychiatric Facility Pro…
In 1908, President Franklin Roosevelt…
The Occupational Safety and Health Adm…
The Outpatient Prospective Payment Sys…
True
False
False
False... Response Feedback: ... The answer is uses Ambulatory Payme…
The Inpatient Psychiatric Facility Pro…
True
In 1908, President Franklin Roosevelt…
False
18 terms
Understanding Health Insurance: Chapter 9
ambulance fee schedule
ambulatory surgical center (ASC)
case mix
chargemaster
payment system for ambulance services provided to Medicare be…
state-lincensed, Medicare-certified supplier of surgical heal…
the types and categories of patients treated by a healthcare…
also know as charge description master (CDM); term hospitals…
ambulance fee schedule
payment system for ambulance services provided to Medicare be…
ambulatory surgical center (ASC)
state-lincensed, Medicare-certified supplier of surgical heal…
52 terms
Understanding Health Insurance
Health insurance specialist duties
What are third-party administrations (…
What is a network provider
Case management responsibilities
Person who reviews health related claims to determine the med…
Company that provides health benefits claims administration a…
Physician or healthcare facility under contract to the manage…
Involves the development of patient care plans for the coordi…
Health insurance specialist duties
Person who reviews health related claims to determine the med…
What are third-party administrations (…
Company that provides health benefits claims administration a…
50 terms
UNDERSTANDING Health Insurance
The document submitted to the payer re…
The Centers for Medicare and Medicaid…
A healthcare practioner is also called a
Which is the most appropriate response…
health insurance claim
Department of Health and Human Services
provider
Explain that the physician is with a patient, and ask if the…
The document submitted to the payer re…
health insurance claim
The Centers for Medicare and Medicaid…
Department of Health and Human Services
32 terms
Chapter 16 Understanding Health Insurance
who is tricare health care program for
when was tricare implemented
what was tricare formually known as
why was tricare created
-active duty military and members of thier families... -eligibil…
1967
champus
-to expand healthcare acess... -to ensure quality of care... -contr…
who is tricare health care program for
-active duty military and members of thier families... -eligibil…
when was tricare implemented
1967
36 terms
Understanding Health Insurance
Fee- for service plan
Managed Care organization
What does utilization management do?
Second surgical opinion
Reimburse providers for individual health services rendered,…
Is a organization responsible for the health of a group of en…
It is a method of controlling healthcare costs and quality of…
Second physician is asked to evaluate the necessity of surger…
Fee- for service plan
Reimburse providers for individual health services rendered,…
Managed Care organization
Is a organization responsible for the health of a group of en…
26 terms
Understanding Health Insurance
Which was the first commercial insuran…
Which replaced the 1908 workers' compe…
The first Blue Cross policy was introd…
The Blue Shield concept grew out of th…
Franklin Health Assurance Company
Federal Employees' Compensation Act
Baylor University in Dallas, Texas
Pacific Northwest
Which was the first commercial insuran…
Franklin Health Assurance Company
Which replaced the 1908 workers' compe…
Federal Employees' Compensation Act
38 terms
Understanding Health Insurance Final
Statute/ Mandates/ Ordinances
Subpoena
Deposition
Interrogatory
Law
Document that requires a witness to appear in court to testify.
Testimony taken under oath taken outside of court.
Court document that consists of a list of questions that must…
Statute/ Mandates/ Ordinances
Law
Subpoena
Document that requires a witness to appear in court to testify.
56 terms
Understanding Health Insurance-Chapter Two
Health Insurance
Group Health Insurance
Federal Employees' Compensation Act (F…
Hill-Burton Act
A contract between a policyholder and a third-party payer or…
Traditional healthcare coverage subsidized by employers and o…
This replaced the 1908 workers' compensation legislation, and…
This provided federal grants for modernizing hospitals that h…
Health Insurance
A contract between a policyholder and a third-party payer or…
Group Health Insurance
Traditional healthcare coverage subsidized by employers and o…
10 terms
Understanding Health Insurance ch4
Processing and Insurance Claim
CMS-1500 claim
Accepting Assignment
Accepting Assignment
-CMS-1500 claim is used to report Professional and technical…
-Requires responses pertaining to patient's condition and if…
when provider agrees to what the insurance company allows and…
continue...... -Claim is proofread and double checked:... any supp…
Processing and Insurance Claim
-CMS-1500 claim is used to report Professional and technical…
CMS-1500 claim
-Requires responses pertaining to patient's condition and if…
32 terms
Understanding Health Insurance - Chapter 1
health insurance claim
preauthorization
hold harmless clause
healthcare provider
the documentation submitted to a third-party payer or governm…
prior approval
clause within the insurance contract that indicates that the…
a physician or other healthcare practitioner
health insurance claim
the documentation submitted to a third-party payer or governm…
preauthorization
prior approval
10 terms
UNDERSTANDING HEALTH INSURANCE CHAP 8
certificate of medical necessity (CMN)
durable medical equipment (DME)
durable medical equipment, prosthetics…
durable medical equipment, prosthetics…
prescription document for durable medical equipment, services…
canes, crutches, walkers, commode chairs, blood glucose monit…
defined by Medicare as equipment that can withstand repeated…
supply patients with durable medical equipment (DME) (e.g., c…
certificate of medical necessity (CMN)
prescription document for durable medical equipment, services…
durable medical equipment (DME)
canes, crutches, walkers, commode chairs, blood glucose monit…
18 terms
UNDERSTANDING HEALTH INSURANCE CHAP 17
adjudication
arbitration
Energy Employees Occupational Illness…
Federal Black Lung Program
judicial dispute resolution process in which an appeals board…
dispute-resolution process in which a final determination is…
provides benefits to eligible employees and former employees…
enacted in 1969 as part of the Black Lung Benefits Act; provi…
adjudication
judicial dispute resolution process in which an appeals board…
arbitration
dispute-resolution process in which a final determination is…
68 terms
UNDERSTANDING HEALTH INSURANCE CHAP 7
care plan oversight services
case management services
Category I codes
Category II codes
cover the provider's time supervising a complex and multidisc…
process by which an attending physician coordinates and super…
procedures/services identified by a five-digit CPT code and d…
optional performance measurement tracking codes that are assi…
care plan oversight services
cover the provider's time supervising a complex and multidisc…
case management services
process by which an attending physician coordinates and super…
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