SBGR ALH 151 Week 5 Ch 18 & 19 Pearson's (2012 EK)
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each of the black spaces below before clicking
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| assignment of benefits | patient's written authorization giving the insurance company the right to pay the physician directly for billed charges
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| birthday rule | used by insurance claim administrators to determine which parent's benefit plans will pay for the medical bills of a dependent child when the child is covered by the plans of both parents
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| breach of confidentiality | failure to keep patient information confidential; occurs when patient information is released to others without authorization from the patient
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| clean claim | health insurance claim form that has been completed correctly without any errors or omissions
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| clearinghouse | independent entity that reviews claims, requests clarification from the provider, and "clean" claims ensuring accurate information is documented, then submits claims to insurance companies in proper format.
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| CMS-1500 | most common health insurance claim form used to file claims for physician's services
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| Denied claim | occurs when procedures or services are not covered by the patient's insurance policy or when the patient has not met his/her deductible
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| dirty claim | a health insurance claim form that is incorrect because it has missing data or has errors
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| invalid claim | health insurance claim form that has been completed but contains some type of incorrect information
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| nonparticipating provider | a physician to whom the patient is expected to pay charges before submitting that claim to the insurance company, which pays the patient directly
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| primary insurance | medical insurance coverage provided through tte patient''s employer
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| secondary insurance | when the patient has medical insuranc ethrough their owbn employer nd thepatient's spouse also has medical insurance through their employer the insurance coverage throughout the spouse is considered secondary.
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| write-off | to agree to forfeit the amount the insurance
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| Current Procedural Terminology (CPT) | code book for procedures and services performed by physicians
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| established patient | one who has been seen within the past 3 years by any practitioner
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| Evaluation and Management (E/M) | codes for services such as office visits, consultations, the physician's component the emergency services and inpatient care
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| International Classification of Diseases, Ninth Revision, Clinical Modification | ICD-9-CM: the code book for diagnosed diseases
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| International Classification of Diseases, Tenth Revision (ICD-10) | most recent edition of the code book for diagnosed diseases
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| kickback | incentive provided by physicians, laboratories, hospitals, or pharmaceutical representatives for use in their practices.
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| modifier | two-digit code preceded by a hyphen that clarifies the procedure (e.g. a procedure that was done on both arms instead of only one.)
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| new patient | patient who has never been seen by anyone in the practice, or who has not been seen by any practitioner of the same specialty in the same practice for more than 3 years.
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| principal diagnosis | diagnosis of a particular condition for which a patient sought care on a particular date, suing when performing codidn in the hospital seetin gand whenn a final dianosis cannort be determined without futher patient follow-up
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| procedural coding |
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| symbols |
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| upcoding |
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| World Health Organization (WHO) |
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