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officebilling1,2,7,8

physician office billing CH

Question	Answer
fixed prepayment to medical provider for all necessary services provided to a plan member patient(Pt)	capitaiton
payment made after the Pt receives services	retroactive payment
amount that the insured pays on covered services before benefits begin	deductible
a percentage of each claim that the insured pays	coinsurance
plan in which members can visit any specialists in their network w/o a referral from their PCP	PPO
controlled drug costs from a list of selected pharmaceuticals as determined by an HMO	formulary
failure to perform medical duties properly	negligence
face to cace meeting with a Pt	encounter
concise statement that describes symptoms, problem condition or diagnosis that Pt gives during encounter	chief complaint
electronic format used to verify benefits	HIPPA eligibility for Health Plan
the most a payer will pay any provider for that work	allowed charge
employers that offer health plans to employees w/o using third-party insurance carriers	self-funded health plan
total amount that will be paid for a covered persons covered expenses during their lifetime	maximum benefit limit
ten-digit number for the insurance policyholder or guarantor	taxonomy code
3 government-sponsored health care programs	medicare - medicaid - tricare
an example of a secondary provider identifier would be what?	the physicians EIN number
violating the HIPPA Privacy Rule can result in what	both civil and criminal penalties
medicare typically pays for what percentage of allowed charges 50, 60, 70 or 80%	80%
how many diagnosis code pointers can be assigned to a procedure code?	4
the NPI is used to report what on a claim	provider identifier
a system used to encode elements of data	code set
downcoding means	billing at a lower level code than what was proformed
what type of coding uses diagnoses that are not coded to the highest level	truncated coding
the physician who actually provided the service is called what	rendering provider
CMS stands for	centers for medicare and medicaid services
PCP	primary care provider
EDI	eletronic data interchange
EHR	eletronic health records
PMP	practic management program

Created by: cpar on 2011-12-05

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officebilling1,2,7,8

physician office billing CH