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