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Health Insurance Chapter 1

An insurance agreement that guarentees repayment for financial losses resulting from an employee's act or failure to act. Protects employers financial operations. Bonding Insurance
The administrative agency within the federal department of health and human services. Centers for Medicare and Medicaid Services
Published by the AMA and includes 5 digit numeric and alphanumeric codes and descriptions for procedures and services Current Procedural Terminology (CPT)
Mutual exchange of data between the provider and insurance company Electronic Data Interchange (EDI)
Provides protection from claims that contain errors and omissions resulting from professional services provided to clients (also called professional liability insurance) Errors and Omissions Insurance
The principles of right and or good conduct Ethics
A report detailing the results of processing a claim Explanation of benefits
Published by CMS, and include 5 digit numeric and alphanumeric codes for procedures, services,and supplies not classified in CPT HCPCS Level II Codes (aka-National Codes)
COnsists of two levels: Current Procedural Terminology, and National Codes (or HCPCS Level II codes) Healthcare Common Procedure Coding System
The healthcare provider cannot collect the fees from the patient Hold Harmless Clause
A person who performs services for another under an express or implied agreement and who is not subject to the other's control, or right to control. Independent Contractor
Linking every procedure or service code reported on the claim to an ICD-9 condition code t hat justifies the necessity for performing that procedure or service Medical Necessity
Prior approval for treatment Preauthorization
Protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising Professional Liability Insurance
A notice sent by the insurance company that contains payment information about a claim Remittance Advice
The documentation submitted to the payer requesting reimbursement is called a... Health Insurance Claim
The Centers for Medicare and Medicaid Services (CMS) was previously called the.... Health Care Financing Administration
A health care practitioner is also calle a... Provider
The mutual exchange of data between provider and payer is called... Electronic Data Interchange
The process of assigning diagnoses, procedures, and services using numeric and alphanumeric characters is called.... Coding
If the health plan preauthorization requirements are not met by providers,.. Payment of the Claim is denied
Which coding system is used to report diagnosis and conditions on claims? ICD
The CPT coding system is published by the... AMA
National codes are associated with... HCPCS
Which report is sent to the patient to detail the results of claims processing? Explanation of Benefits
A remittance advice contains... Payment information about a claim
Which type of insurance guarantees repayment of financial loss resulting from an employee's act or failure to act? Bonding
Medical malpractice insurance is a type of what insurance? Liability
Which mandates workers' compensation insurance to cover employees and their dependenat against injury and death occurring during the course of employment? State
The American Medical Billing Association offers which certification exam? CMRS
The concept that every procedure or service reported to a third-party payer must be linked to a condition that justifies that procedure or service is called? Medical Necessity
The administrative agency responsible for establishing rules for Medicare claims processing is called the..... Centers for Medicare and Medicaid Services
Documentation submitted to an insurance company requesting reimbursement for health care services provided is called a.... Health Insurance Claim
Which organization is responsible for administering the Certified Healthcare Reimbursement Specialist certification exam? AMBA
Which clause is implemented if the requirements associated with preauthorization of a claim prior to payment are not met? Hold Harmless Clause
Data published in the Occupational Outlook Handbook indicates the job opportunities for health insurance specialists will increase by what percentage? 9-17 percent
The exchange of information between provider and third-party payer, using a standardized machine-readable format, is called.... Electronic Data Interchange
The process of reporting diagnoses, procedures and services as numeric and alphanumeric characters on an insurance claim is.... Coding
Which is another title for the health insurance specialist? Claims Examiner
Which type of insurance should be purchased by health insurance specialist independent contractors? Medical Malpractice
A health insurance specialist who is able to demonstrate cometency in facilitating the claims reimbursement process from the time a service is rendered by a provider until the balance is paid can qualify for which certification? Certified Medical Reimbursement Specialist (CMRS)
Which certification fulfills the need for an entry-level coding credential? Certified Coding Assistant (CCA)
Created by: kduvall20