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Fri test

chapters 15 and 16

Anaphylaxis sever allegic reaction
CPR mouth barrier disposable barrier device used to prevent infection
crash cart wheeled cart that contains emergency medical equipment
defibrilator device that delivers an electric shock to a patient
syncope fainting; the sudden loss of consciousness
AAMA American Association of Medical Assistants
ABCD airway, breathing, circulation, defibrilation
AED automatic external defibrillator
AHA American Heart Association
CPR cardiopulmonary resuscitation
FEMA Federal Emergency Management Agency
HEPA high efficiency particulate air filter
OSHA Occupational Safety and Health Administration
PPE personal protective equipment
abstract te process of locating data in multiple source documents and accurately transferring it to a form
accept assignment physician agrees to accept the amount approved by the insurance company as payment in full for a given service
advance beneficiary notice a form patients sign agreeing to pay for covered Medicare services that may be dened due to medical necessity or frequency
allowed amount the dollar amount for a service that an insurance company considers acceptable and uses to determine benefit payments AKA: approved amount
ancillary coverage insurance coverage for services provided by other than a physician or hospital, such as dental, vision, or chiropractic care
appeal process of asking for a review of a denied service or claim
approved amount see allowed amount
assignment of benefits request made by a patient to allow the insurance carrier to pay the health cre professional directly rather than issuing monies to the patient
balance billing billing a patient for the dollar difference between the provider's charge and the insured approved amount; usually not permitted for participating providers
beneficiary person who is elegible to receive benefits/services under an insurance policy
birthday rule the parent with the birthday earlier in the year is the primary carrier for the children; the parent with the later birthday is the secondary carrier
bundling combining multiple services under a single all inclusive CPT code and one charge
capitation plans health care plans in which providers are paid set fees per month per member patients
caretaker person or entity responsible for determining when and if a patient needs specific types of halth care; also called a gatekeeper or primary care provider (PCP)
carve outs services that are reimbursed in addition to the base rate for the patient
catastrophic large and usually unforeseen
categorically needed Medicaid eligible patients who qualify for cash assistance as well as medical services
certificate of coverage a letter from the insurance company that provides proof of type and timeframe of coverage when a patient teminates a health insurance policy
charge slip document on which the physician indicates procedure and diagnosis codes; also called a routing slip; or see an encounter form
clean claim insurance claim with no data errors
coinsurance percentage of medical charges patients are responsible for according to their insurance plan contracts
commercial insurance see private insurance
consumer-directed health care plans health insurance plana that place patients in charge of how hteir health care dollars are spent
conversion factor a constant dollar value multiplied by the relative value unit to determine the price of individual services
coordination of benefits the process of determining which insurance policy should be billed first, second, or third when a patient is covered by multiple policies
copayment set dollar fee per visit or service that patients are responsible for according to their insurance plan contracts
covered services potentially eligible for reimbursement
deductable monetary amount patients must pay to the provider for health care services before their health insurance benefits begin to pay
denied a claim processed by an insurer and determined not eligible for payment
dependent a family member or other individual who qualifies for coverage on the insured's policy; also called beneficiary, SEE ALSO insured;policy holder
disability insurance insurance that covers other benefits due to a disability that prevents the individual from working
e-billing process of sending health insurance claims electronically
elective procedure procedure that will benefit the patient but does not need to be scheduled immediately
encounter form document in which te physician indicates procedure ad diagnosis codes; also called a routing slip or charge slip
end-stage renal disease total or nearly complete failure of the kidneys
exclusions procedures or services not covered under an insurance plan
exclusive provider organization a managed care contract with a smaller network of providers under which the employer agrees not to use any other networks in return for favorable pricing
explanation of benefits a statement that accompanies payment from the insurance company which summarizes how the payment for each billed service was calculated and gives reasons for any items not paid
fee-for service process in which insurance companies pay providers fees for each service provided to covered patients
fee schedule list of the approved fees insurance carriers agree to pay to participating providers wh agree to contract with the carriers; also refers to the standard set of fees the provider chares to all insurers
flexible spending account account into which employees place pretax earnings for projected medical expenses; also called health care reimbursement account
form locators the boes to be completed on the CMS-1500 claim form
formulary tiered list of drugs covered by an insurance company
gatekeeper see caretaker
generic drugs low-cost medications that duplicate their name brand counterparts in active ingredients and effect
geographical adjustment factor (GAF) a numeric multiplier used by Medicare to adjust fees for the varying costs of practicing medicine in different areas of the country
group health insurance a commercial insurance policy with rates based on a group of people, usually offered by an employer
health care reimbursement account see flexible spending account
health maintenance organization a group of physicians or medical centers that provides comprehensive service to members under a capitated payment plan; members care is covered only when using the designated providers
health savings account tax free savings account used for medical expenses in conjunction with a high deductable health plan
hospice facility or service for patients who are diagnosed with terminal illness and are expected to have 6 or fewer months to live
hospital services patient care provided by a licensed acute care hospital
indemnity see fee for service
individual insurance a commercial insurance policy with rates based on individual health criteria
individual practice association HMO'S tht are the most decentralized and involve contracting with individual physicians to create a healthcare delivery system
inpatient a person who is admitted to the hospital for a minimum of 24 hours
insured person who holds or owns an insurance policy; same as the member or the policyholder
liability insurance type of insurance that covers injuries that occur on, in, or because if the insured's property
lifetime maximum benefit monetary amount aloowed by an insurance carrier for a covered member's covered expenses over the member's lifetime
limiting charge the maximum amount a Medicare non-PAR provider may bill the patient on an unassigned claim; 115% of the non-PAR fee schedule
long term disability insurance insurance that covers lost wages and certain other benefits due to a disability that prevents the individual from working, usually for more than one year
managed care a system of healthcare delivery focused on reducing costs by transferring risk to the provider and may limit the type and frequency of care members may receive
Medicaid a joint federal and state program that helps with medical costs for some people with low incomes and limited resources
medical nessecity criteria establishing when a service is appropriate
medical savings account tax-free savings account for small employers and self-employed; used for medical expenses in conjunction with a high-deductable health plan
medically needy Medicaid-eligible patients who are eligible for medical services, but not cash assistance
Medicare federal program that covers medical expenses for those aged 65 and over, those with end-stage renal disease, and those with long term disabilities
member the person who owns the insurance policy
negotiated fee schedule a common reimbursement method in managed care whereby the MCO develops a list of fees for providers that they agree to accept in the participationg provider contract.
non-covered services not eligible for reimbursement under any circumstances
nonparticipating provider health care provider who has not contracted with a particular health insurance carrier
outliers exceptional circumstances that cost far more or less than average
outpatient a person who receives medical care at a hospital or other medical facitlity but who is not admitted for more than 24 hours
participating provider health care provider who has contracted with a particular health insurance carrier
past timely filing limits tme beyond which an insurance carrier will accept an insurance claim
payor number unique identifying number assigned to each insurance carrier for the purpose of directing electronic claims
per case per case payment method is used for hospitals; under this method, the hospital receives a pre-established amount per patient for the entire stay, based on the patient's diagnosis, regardless of how long htey are in or what services were provided
per diem PER DAY payment method whereby the facility is paid a flat amount per day the patient remains, regardless of what services are provided
physician services patient care provided by a licensed physician
point of service an insurance offering in which a patient has acces to multiple plans, such as HMO
policyholder person who holds or owns an insurance policy; same as the member or the insured
preauthorization approval for treatment or service obtained from an insurance company before the care is provided
precertification see preauthorization
pre-existing condition condition for which a patient received treatment in certain time period before beginning coverage with a new insurance plan
preferred provider organization organization that contracts with independant providers to preform services for members at discounted rates
premium dollar amount paid to the insurance company to have coverage in force; usually paid monthly; employers may pay part or all of the premium as an employee benefit
preventative care health care designed to keep a person healthy
private insurance insurance not provided by the government but by an independant not-for-profit or for-profit company; also called commercial insurance
rejected a claim that is returned to the provider without processing due to a technical error
relative value unit unit of measurment assigned to medical services based on the resources required to provide it, includes work, practice expense, and liability insurance
resource based relative value scale the methodology Medicare uses to establish physician fees, based on the relative value unit, the geographical adjustment factor, and the conversion factor
respite care temporary care provided by an outside party to relieve the usual caregiver
self-insurance type of insurance where rather than purchasing a commercial insurance policy, an employe sets aside a large reserve fund to directly reinburse employees for medical expenses
skilled nursing facitlity a licensed facitlity whih primarily provides inpatient, skilled nursing care to patients who require medical, nursing, or rehabilitative services but does not provide the level of are or treatment available in a hospital
sliding scale fee a provider's fee schedule that charges varying fees for the service based on a patient's financial ability to pay
staff model HMO employs salaried physicians who treat members in facilities owned an operated by HMO
stop loss the max amount the patient must pay out-of-pocket for copyments and coinsurance
subscriber person who holds or owns an insurance policy; same as the member, or see the insured
superbill document on which the physician indicates procedure and diagnosis codes; also called a routing slip or an encounter form
third-party administrator a company that processes paperwork for claims for a self-insured employer
TRICARE health insurance administered by the U.S. Dept of Defense for active duty military personnel, retired service personnel, and their eligible dependents; formally known as Civilian Health and Medical Program (CHAMPUS)
unbundling billing multiple services with seperate CPT codes and sperate charges that should be combined under a single CPT code and one charge
usual, customary, and resonable (UCR) fee a fee determined by third party payers to reimburse providers based on the provider's normal fee, the range of fees charges by provider's of the same specialty in the same geographical area, and other factors to determine app. fees in unusual situations
waiting period period after a new health insurance plan begins during which certain services are not covered
waiver see advance beneficiary notice
worker's compensation insurance coverage for job-related illness or injury provided by employers
ABN advance beneficiary notice
ADA American Dental Association
CDHP Consumer Directed Health Plan
CF conversion factor
CHAMPVA Civilian Health ad Medical Program of the Veterans Administration
CMS Centers for Medicare and Medicaid
COB coordination of benefits
COBRA Consolidated Omnibus Budget Reconciliation Act
CPT Current Procedural Terminology
CSRS civil service
DEERS defense enrollment eligibility reporting system
DME durable medical equipment
EMC electronic media claims
EOB explination of benefits
EPO Exclusive provider organization
ESRD end-stage renal disease
FERS Federal employee retirement system
FL form locator
FSA flexible spending account
GAF geographical adjustment factor
HCFA Health Care Financing Administration
HCRA health care reimbursement account
HIPAA Health Insurance Portability and Accountability Act
HMO health maintenance organization
HSA Health Savings Account
Created by: boncka