Terminology
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| Today, the “Blue System” is the largest single processor of Medicare Part A claims, which is commonly referred to as a | fiscal intermediary
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| A document prepared by the carrier that gives details of how a claim was adjudicated is called a/an | explanation of benefits
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| A healthcare provider trained in a specific medical specialty is a | specialist
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| A healthcare delivery system that controls use and cost of services while providing enrollees access to quality, cost-effective healthcare is called _____ care. | managed
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| Coverage that includes treatment for long, high-cost illnesses or injuries is referred to as | major medical
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| The type of provider that enters into a contractual agreement with the carrier and agrees to follow the payer’s specific guidelines in return for certain advantages is called a ________ provider. | PAR
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| Services or supplies that are appropriate and necessary for the symptoms, diagnosis, and treatment of the medical condition and meet the standards of good medical practice is the definition for | medical necessity
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| A type of HMO whereby services are provided by outpatient networks composed of individual healthcare providers who supply all necessary patient care is a/an | IPA
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| Individuals who have been denied coverage due to a preexisting condition and have been without coverage for a period of at least 6 months may acquire healthcare insurance through a/an | high-risk pool
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| A system designed to determine the medical necessity and appropriateness of a requested medical service or procedure is a/an | utilization review
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| A business entity that specializes in consolidating claims received from providers and transmitting them in batches to each respective third-party payer is a | clearinghouse
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| A combination of both basic and major medical insurance is called | comprehensive
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| A multispecialty practice in which healthcare services are provided within the building complex owned by the health maintenance organization (HMO) is referred to as a/an | staff model
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| A claim that has no errors or omissions and can be processed without delays is called a _____ claim. | clean
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| Submitting insurance claims directly to a third-party payer is called | direct data entry
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| The “traditional” type of health insurance policy whereby the insurance company pays all or a portion of the fees for the services provided to the individual covered by the policy is called | fee-for-service (FFS)
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| The document on which patients record their demographic and insurance information is the | patient information form
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| Individuals who are members of a managed care plan are commonly referred to as | enrollees
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| A person’s health insurance coverage that has been in effect for a period of 63 days or more before enrolling in a new health plan is called | creditable coverage
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| Insurance companies are referred to as _____ payers. | third-party
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| The kind of health insurance paid for by a business entity other than the government is called | commercial health insurance
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| Supplemental documents that provide additional information to the claims processor that normally cannot be included within the electronic claim format are | claim attachments
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| Many FFS policies set a limit on the amount of reimbursement for any charges incurred by members, which is referred to as a/an | lifetime maximum insurance cap
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| A procedure required by most healthcare plans before a provider carries out specific procedures or treatment is a/an | preauthorization
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| An amount after which the insurance company will not pay any more of the charges incurred for one incident or in any one year is commonly called a/an | insurance cap
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