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Insurance Billing
YBI Insurance Proc Chaps 11, 12, 13
| Question | Answer |
|---|---|
| ABN | Advanced Beneficiary Notice |
| CMS | Centers for Medicare and Medicaid Services |
| copay | copayment |
| EBP | Employee Benefit Plan |
| EGHP | Employee Group Health Plan |
| ERA | Electronic Remittance Advice |
| ESRD | End Stage Renal Disease |
| FPL | Federal Poverty Level |
| MAC | Medicare Administrative Contractor |
| MCO | Managed Care Organization |
| MN | Medically Necessary |
| MSN | Medicare Summary Notice |
| SCHIP | State Children's Health Insurance Program |
| SLMB | Specified Low-income Medicare Beneficiary |
| SMI | Supplementary Medical Insurance |
| SSI | Supplemental Security Income |
| TANF | Temporary Assistance to Needy Families |
| What is an agreement given to the patient to read and sign before rendering a service if the participating physician thinks that it may be denied for payment? | ABN |
| What are supportive services other than routine hospital services provided by the facility, such as x-ray films and lab tests? | Ancillary Services |
| What is a system of payment used by managed care plans in which physicians and hospitals are paid a fixed per capita amount for each patient enrolled? | Capitation |
| Who are the aged, blind, or disabled individuals or families and children who meet financial eligibility requirements? | Categorically Needy |
| What is a cost-sharing requirement under a health insurance policy providing that the insured will assume a percentage of the costs for covered services? | Coinsurance |
| What is a patient's payment of a portion of the cost at the time the service is rendered? | Copayment |
| What are specific services and supplies for which Medicaid will provide reimbursement? | Covered Services |
| What is a specific dollar amount that must be paid by the insured before a medical insurance plan or government program begins covering health care costs? | Deductible |
| What is a type of managed health care plan that combines features of HMOs and PPOs? It is offered to large employers who agree not to contract with any other plan. | EPO |
| Who is one who controls patient access to specialists and diagnostic testing services? | Gatekeeper |
| What is the oldest of all of the prepaid health plans? It provides a wide range of health care services with an emplasis on preventive medicine. | HMO |
| What is a percentage limit on fees that nonparticipating physicians may bill Medicare beneficiaries above the fee schedule amount? | Limiting Charge |
| What is a generic term applied to a managed care plan? | Managed Care Organization |
| What is a federally aided, state-operated and state-administered program that provices medical benefits for certain low-income persons in need of health and medical care? | Medicaid |
| What is ther performance of services and procedures that are consistent with the diagnosis benefits for certain low-income persons in need of health and medical care? | Medical Necessity |
| What are hospital benefits of a nationwide health insurance program for persons age 65 and older? | Medicare Part A |
| What is medical insurance of a nationwide helath insurance program for persons age 65 and older? | Medicare Part B |
| What is the Medicare Plus Choice plans that offer a number of health care options in addition to those available under Medicare Parts A and B? | Medicare Part C |
| What is a stand alone prescription drug plan, presented by insurance and other private companies that offer drug coverage that meets the standards established by Medicare? | Medicare Part D |
| What is it called when the primary insurance plan of a Medicare beneficiary that must pay for any medical care or services first before Medicare is sent a claim? | Medicare Secondary Payer |
| Who are persons in need of financial assistance or whose income and resources will not allow them to pay for the costs of medical care? | Medically Needy |
| Who is a physician who contracts with a HMO or other insurance company to provide servcies? This physician has agreed to accept a plan's payments for servces to subscribers. | Participation Physician - par |
| What is a physician owned business that has the flexibility to deal with all forms of contract medicine and still offer its won packages to business groups, unions, and the general public? | Physician Provider Group |
| What is a managed care plan in which members are given a choice as to how to receive servies, whether through a HMO, PPO, or fee-for-service plan? | POS Plan |
| What is a type of health benefit program in which enrollees receive the highest level of benefits when they obtain services from a physician, hospital, or other health care provider? | PPO |
| Who is the physician who oversees the care of patients in a manged health care plan (HMO or PPO) and refers patients to see specialists for services as needed? | PCP |
| What is the evaluation of a provider request for a specific service to determine the medical necessity and appropriateness of the care requested for a patient? | Prior Approval |
| What are services requested by a specialist from another specialist? | Tertiary Care |
Created by:
dsljulian
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