STUDY GUIDE, QUIZES, AND TEST
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| Review Linkage Protocol | Appropriateness of codes, payers rules about linkage, documentation to support codes. Compliance with regulation and guidelines.
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| Plus Sign indicates | add on codes
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| Life Cycle of a Claim | Submission, Processing, Adjudication, Non-Covered, Unauthorized, Medical Necessity Checks, Payment/RA/ERA
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| CMS 1500 Universal Claim Forms | Claim developed by the AMA and the Centers for MCR and Medicaid services used by physicians and other professionals to bill outpatient services and supplies to Tricare MCR and some Medicaid programs and some private insurance and managed care plans.
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| PPO | PPO is similar to an HMO, but care is paid for a received instead of in advance in form of a schedule PPO may offer more flexibility by allowing for visits to out-of-network require only the payment of a small fee
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| Modifier 50 | bilateral procedure
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| TRICARE PRIME (HMO) | An HMO type plan in which enrollees receive health care through a Military Treatment Facilities PCM or a supporting network of civilian providers.
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| Pathology and Laboratory | 80048-89356
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| HIPAA is and acronym for | Health Insurance Portability and Accountability Act of 1996
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| Six Section of CPT | E&M, Anatomical Site, Condition or Disease, Synonym or Eponym, Abbreviation
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| Health Maintenance Organization, a form of health insurance combining a range of coverage in a group basis. A group of doctors and other medical professionals offer care through the HMO for a flat monthly rate with no deductibles. | HMO
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| Heath indemnity Insurance is a fee for service Insurance that is sometimes used when a person is in between health plans, and will cover some (but not all) expenses | Indmity Insurance
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| Patient Information, Verify Insurance, Prepare encounter form, Code DX and CPT, Review Linkage Protocol, Calculate Physicians charges, Prepare Claim Transmit Claim, Follow up on Reimbursement | Basic Billing Reimbursement Steps
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| Any Medicare Claim that contains complete necessary information but is illogical or incorrect (e.g. listing an incorrect provider number for referring physician) Invalid Claims re identified to the provider and maybe resubmitted | Invalid Claim
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| Private individuals are responsible for securing their own Health Insurance coverage, Commercial Government Employer, Group Health Insurance coverage | Private payer vs Commercial
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| 77010-79999 | Radiology
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| Category I: Procedures that are consistent with contemporary medical practice and are widely performed. Category II: Supplementary tracking used for performance measure, Category III: Temporary codes for emerging technology, service and procedures. | Three Categories for E'M codes
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| A Notice that a doctor, supplier, or provider gives a Medicare beneficiary/before furnishing an item or service if the doctor, supplier, or provider believes that Medicare may deny payment | ABN/Advanced Beneficiary Notice
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| A rejected claim is any electronically submitted claim that is un processable due to missing or invalid information required by the payer. | Rejected Claim
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| Change in wording | Triangle means
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| Used to enclose synonyms alternative wording or and explanatory phrase | brackets
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| Level 2 Codes | National Codes for physicians and non-physicians service not found in the CPT Level 1
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| Basic Billing Reimbursement Steps | Patient information, Verify Insurance Prepare encounter form, Code DX and CPT, Review Linkage Protocol, Calculate physicians charges. Prepare claim, transmit claim, follow up on reimbursements
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| BULLETS | Represents a new procedures or service code added since the previous edition of the manual
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| Circle with a line through it means | modifier 51 exempt codes
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| Elecontric Claim | An insurance claim submitted to the insurance carrier via a central processing unit (CPU), tape, diskette, direct data entry, direct wire, dial-in telephone, digital fax, or personal computer download or upload
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| Insurance policy that pays benefits in the event that the policy holder becomes incapable of working | Disability Insurance
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| free or low-cost health insurance coverage through the state | Medicaid
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| New procedure Code | bullet means
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| Refer to the base amount that is treated as the standard or most common charge for a particular medical service when rendered in a particular geographic area | Usual Customary and reasonable
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| Listed under associate and stand alone codes | Indented codes
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| Provide Medicaid to certain groups not otherwise eligible for Medicaid must cover: Pregnant Women, Children under 18, States have option to cover, Children up to 21, Parents and other care takers relatives, Elderly, Individuals with disabilities | Medicaid Medially Needy
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| A distinction for individuals who fall into a specific category (or criteria) or mandatory Medicaid Eligibility established by the federal government. These categories apply to every state Medicaid program | Medicaid Catagorically needy
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| Worker's Compensation is a job benefit that provides money and services to employees that are injured or become sick on the job. Worker's Compensation helps injured and sick workers to survive financially as they recover form health problems | Workman's Comp
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| Health Care Programs for Uniformed Service members, retirees, and their families | TRICARE
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