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Medical Billing/Code

Study Guide

TermDefinition
Renewable Provision Policy Grants the insurer the right to cancel the policy at any time.
Optionally Renewable Policy The insurer right to refuse to renew the policy on a specific date (anniversary date.
Conditionally Renewable Policy The insurer has limited right to refuse to renew a health insurance policy.
Guaranteed Renewable Policy The policy renews as long as the premium is paid.
Non-cancelable Policy Insurer cannot increase the premium unless the insurer has reached the age specified in the contract.
Blue Cross/Blue Shield Non-profit policy providing prepaid health care service.
CHAMPUS Civilian Health&Medical Program of Uniformed Services Used for active duty and family.
CHAMPVA Civilian Health&Medical Program of Veteran Administration Used for veterans and disable veterans.
CMP Competitive Medical Plan Medicare benefits enrolled into managed care plans
EPO Exclusive Provider Organization Uses services of limited network of provides.
Assignment Transfer of right for payment from patient to physician.
Indemnity Benefits paid to the insurer
Premium Payment required to be paid to keep insurance current
Deductible The amount the insurer pays before the policy pays.
Exclusion Certain benefits or illnesses not covered by policy.
Carrier The insurance company.
Statue of Limitations An insurer has 3yrs to bring legal action to a claim.
Preauthorization Type of approval required; prior to procedure.
Precertification Type of approval to determine if treatment is covered.
HCFA 1500 Health Insurance Claim Form Insurance claim is submitted is submitted on this form.
Eponyms Represents disease names and should not be used in billing.
Dingy Claims The claim is held until chgs within the system allows payment
Dirty Claims Claims with errors that manual processing.
Rejected Claims Claims that require an investigation.
Clean Claims Claims submitted with all important information in a timely matter(60days).
How long are medical records for Medicare recipients kept? 7years
How long are medical records for Deceased recipients kept? 5years
How long are medical records for Radiology injuries recipients kept? 20-30years after radiation exposure
How long are medical records for Active recipients kept? Indefinite retention
Changing dates of service is an example of? Fraud
Billing for services not rendered is an example of? Fraud
Up coding is an example of? Fraud
Claims for services not medical necessary is an example of? Abuse
Excessive charges for services or supplies is an example of? Abuse
Billing Medicare beneficiaries at a higher rate is an example of? Abuse
Breaching assignment agreement is an example of? Abuse
Altering fees on a claim form to obtain higher payment is an example of? Fraud
All records are confidential except? 1)Signed authorization to release info 2)Workers compensation cases 3)Pt is Suing someone 4)Pt records are subpoenaed
What type of information should not faxed? a)HIV status b) Drug and Alcohol Treatment C)Sexually Transmitted Diseases
What happens when a Pt. misses an appointment? 1)Notated in medical record. 2)Letter is mail out to Pt. notifying the Pt. of missed appt.
When can a patient terminate their contract with the doctor? At anytime
How can a physician terminate the patients contract? In writing with a return signature card.
How do you abstract a medical record? 1)Provide only authorized information to agents 2)Obtain patient signature for release 3)Agent must pay for time and effort 4)Do not release HIV info, even if Pt authorize it.
What is the correct procedures for copying a record for an authorized agent? a)Allow Doctor to review prior to copying b)Agent must make an appt. to copy record c)Agent must pay for supplies and equip.used d)Record does not leave the office e)Must have a signed release.
Malpractice Unreasonable lack of skill that results in an injury.
What are some methods insurance claims is submitted? Optically scanned(if not optically scanned check thoroughly for tampering, Manual, Electronic,Faxed
Identify who is the primary holder in dual coverage; give two examples:` 1)Spousal: Policy is always primary for the holder 2)Children: Parents who birth month comes first on the calendar.
Created by: dajuan77