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Ch. 1 Reimbursement

Health Insurance Specialist Career

QuestionAnswer
Professional association that provides national accreditation and certification, provides education products and network opportunities, and increases and promotes national recognition and awareness of professional coding. American Academy of Professional Coders (AAPC)
Enables medical assisting professionals to enhance and demonstrate required knowledge, skills, and professionalism; protects medical assistants' right to practice. American Association of Medical Assistants (AAMA)
Founded in 1928 to improve the quality of medical records, and currently advances the HIM profession toward an electronic and global environment, including implementation of ICD-10-CM and ICD-10-PCS in 2013. American Health Information Management Association (AHIMA)
Offers the Certified Medical Reimbursement Specialist (CMRS) exam, which recognizes competency of members who have met high standards of proficiency. American Medical Billing Association (AMBA)
An insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee. It protects the financial operations of the employer. Bonding insurance
Protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising. Business liability insurance
Formerly known as the Health Care Financing Administration (HCFA); an administrative agency within the federal Department of Health and Human Services (DHHS). Centers for Medicare and Medicaid Services (CMS)
Employed by third-party payers to review health-related claims to determine whether the charges are reasonable and medically necessary based on the patient's diagnosis. Claims examiner
Process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim. Coding
Published by the American Medical Association; includes five-digit numeric codes and descriptors for procedures and services performed by providers. Current Procedural Terminology (CPT)
The illegal transfer of money or property as a fraudulent action Embezzle
Provides protection from claims resulting from errors and omissions associated with professional services provided to clients as expected of a person in their profession; also called Professional Liability Insurance Errors and Omissions Insurance
Principle of right or good conduct; rules that govern the conduct of members of a profession. Ethics
Report that details the results of processing a claim. Explanation of Benefits (EOB)
National codes published by CMS, which include five-digit alphanumeric codes for procedures, services, and supplies not classified in CPT. HCPCS level II codes
Coding system that consists of CPT, national codes (level II), and local codes (level III); local codes were discontinued in 2003; previously known as HCFA Common Procedure Coding System. Healthcare Common Procedure Coding System (HCPCS)
Physician or other healthcare practitioner. Healthcare Provider
Professionals who manage patient health information and medical records, administer computer information systems, and code diagnoses and procedures for healthcare services provided to patients. Health Information Technician
Documentation submitted to an insurance plan requesting reimbursement for healthcare services provided. Health Insurance Claim
Person who reviews health-related claims to determine the medical necessity for procedures or services performed before payment (reimbursement) is made to the provider; see also reimbursement specialist. Health Insurance Specialist
Policy that the patient is not responsible for paying what the insurance plan denies. Hold Harmless Clause
A person who performs services for another under an express or implied agreement and who is not subject to the other's control, or right to control, of the manner and means of performing the services. Independent Contractor
Coding system used to report diseases, injuries, and other reasons for inpatient and outpatient encounters as well as inpatient procedures. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
Coding system to be implemented on October 1, 2013, and used to report diseases, injuries, and other reasons for inpatient and outpatient encounters. International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
Coding system to be implemented on October 1, 2013, and used to report procedures and services on inpatient claims. International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)
Nonpaid professional practice experience that benefits students and facilities that accept students for placement; students receive on-the-job experience prior to graduation, and the intership assists them in obtaining permanent employement Internship
Policy that covers losses to a third party caused by the insured, by an object owned by the insured, or on the premises owned by the insured Liability Insurance
Employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly. Medical Assistant
Created in 1995 to provide medical billing and coding specialists with a reliable source for diagnosis and procedure coding education and training Medical Association of Billers (MAB)
A type of liability insurance that covers physicians and other healthcare professionals for liability claims arising from patient treatment. Medical Malpractice Insurance
Involves linking every procedure or service code reported on an insurance claim to a condition code that justifies the need to perform that procedure or service. Medical Necessity
Commonly referred to as HCPCS codes; include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT. National Codes (level II codes)
Provides protection from claims resulting from errors and omissions associated with professional services provided to clients as expected of a person in their profession; also called errors and omissions insurance. Professional Liability Insurance
Conduct or qualities that characterize a professional person. Professionalism
Protects business contents against fire, theft, and other risks. Property Insurance
Person who reviews health-related claims to determine the medical necessity for procedures or services performed before payment (reimbursement) is made to the provider; see also health insurance specialists. Reimbursement Specialist
Electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service, type of bill (TOB), charges, payment information, and reas Remittance Advice (remit)
Latin for "let the master answer"; legal doctrine holding that the employer is liable for the actions and omissions of employees performed and committed within the scope of their employment. Respondeat superior
Healthcare services, determined by the state, than an NP and PA can perform. Scope of Practice
Insurance program mandated by the federal and state governments, that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders. Workers' Compensation Insurance
Created by: adale3171