Assignment help-Chapter 15: Medical Billing and Reimbursement


Assignment help-Chapter 15: Medical Billing and Reimbursement 

Assignment #5

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Chapter 15: Medical Billing and Reimbursement

VOCABULARY REVIEW

Fill in the blank with the correct vocabulary terms from this chapter.

Section 1:

1.      The process of obtaining the dollar amount approved for a medical procedure or service before the procedure or service is scheduled.

___________________________________

2.      Obtained from health insurance companies and gives the provider approval to render the medical service.

___________________________________

3.      The electronic transfer of data (e.g., electronic claims) between two or more entities.

___________________________________

4.      A process done prior to claims submission to examine claims for accuracy and completeness.

___________________________________

5.      A contract between a provider and an insurance company in which the health plan pays a monthly fee per patient while the provider accepts the patient’s copay as payment in full for office visits.

___________________________________

6.      The process of obtaining the dollar amount approved for a medical procedure or service before it is scheduled.

___________________________________

7.      Form used by most health insurance payers for claims submitted by providers and suppliers.

___________________________________

8.      Process by which an insurance carrier allows a provider to submit insurance claims directly to the carrier electronically.

___________________________________

9.      A healthcare provider who has signed a contract with a health insurance plan to accept lower reimbursements for services in return for patient referrals.

___________________________________

a.       Precertification

b.      CMS-1500

c.       Direct Billing

d.      Release of information

e.       Participating provider

f.       Electronic data interchange

g.      Capitation agreements

h.      Audit

 


Section 2:

10.  An intermediary that accepts the electronic claim from the provider, reformats the claim to the specifications outlined by the insurance plans, and submits claim.

___________________________________

11.  An identifier assigned by the Centers for Medicare and Medicaid Services (CMS) that classifies the healthcare provider by license and medical specialties.

___________________________________

12.  On the EOB where the payer indicates the conditions under which the claim was paid or denied.

___________________________________

13.  Found on the patient’s health insurance ID card and is needed to identify the specific health plan to which the claim should be submitted.

___________________________________

14.  When provider may be inclined to code to a higher specificity level than the service provided actually involved.

___________________________________

15.  Claims with incorrect, missing, or insufficient data.

___________________________________

16.  A form that is sent by the insurance company to the provider who submitted the insurance claim which an accompanying check or a document indicating that funds were electronically transferred.

___________________________________

17.  Insurance carrier’s decision if the tests and treatments indicated by the CPT and HCPCS codes meet the accepted standard of practice to treat the patient’s diagnosis indicated by the ICD code.

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18.  A patient financial responsibility that the subscriber for the policy is contracted per year to pay toward his or her healthcare before the insurance policy reimburses the provider.

___________________________________

19.  When a lower specificity level, or more generalized code is assigned.

___________________________________

20.  A policy provision in which the policyholder and the insurance company share the cost of covered medical services in a specified ratio.

___________________________________

21.  A patient financial responsibility that is due at the time of the office visit.

___________________________________

22.  Determining whether fraudulent medical billing practices were done with purpose or by accident.

___________________________________

a.       Transmitter ID

b.      Claims clearinghouse

c.       Downcoding

d.      Explanation of benefits (EOB)

e.       National Provider Identifiers (NPIs)

f.       Remark codes

g.      Medical necessity

h.      Dirty claims

i.        Copayment

j.        Coinsurance

k.      Intentional

l.        Upcoding

m.    Deductible

Assignment help-Chapter 15: Medical Billing and Reimbursement 

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