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Today, the “Blue System” is the largest single processor of Medicare Part A claims, which is commonly referred to as a fiscal intermediary
A document prepared by the carrier that gives details of how a claim was adjudicated is called a/an explanation of benefits
A healthcare provider trained in a specific medical specialty is a specialist
A healthcare delivery system that controls use and cost of services while providing enrollees access to quality, cost-effective healthcare is called _____ care. managed
Coverage that includes treatment for long, high-cost illnesses or injuries is referred to as major medical
The type of provider that enters into a contractual agreement with the carrier and agrees to follow the payer’s specific guidelines in return for certain advantages is called a ________ provider. PAR
Services or supplies that are appropriate and necessary for the symptoms, diagnosis, and treatment of the medical condition and meet the standards of good medical practice is the definition for medical necessity
A type of HMO whereby services are provided by outpatient networks composed of individual healthcare providers who supply all necessary patient care is a/an IPA
Individuals who have been denied coverage due to a preexisting condition and have been without coverage for a period of at least 6 months may acquire healthcare insurance through a/an high-risk pool
A system designed to determine the medical necessity and appropriateness of a requested medical service or procedure is a/an utilization review
A business entity that specializes in consolidating claims received from providers and transmitting them in batches to each respective third-party payer is a clearinghouse
A combination of both basic and major medical insurance is called comprehensive
A multispecialty practice in which healthcare services are provided within the building complex owned by the health maintenance organization (HMO) is referred to as a/an staff model
A claim that has no errors or omissions and can be processed without delays is called a _____ claim. clean
Submitting insurance claims directly to a third-party payer is called direct data entry
The “traditional” type of health insurance policy whereby the insurance company pays all or a portion of the fees for the services provided to the individual covered by the policy is called fee-for-service (FFS)
The document on which patients record their demographic and insurance information is the patient information form
Individuals who are members of a managed care plan are commonly referred to as enrollees
A person’s health insurance coverage that has been in effect for a period of 63 days or more before enrolling in a new health plan is called creditable coverage
Insurance companies are referred to as _____ payers. third-party
The kind of health insurance paid for by a business entity other than the government is called commercial health insurance
Supplemental documents that provide additional information to the claims processor that normally cannot be included within the electronic claim format are claim attachments
Many FFS policies set a limit on the amount of reimbursement for any charges incurred by members, which is referred to as a/an lifetime maximum insurance cap
A procedure required by most healthcare plans before a provider carries out specific procedures or treatment is a/an preauthorization
An amount after which the insurance company will not pay any more of the charges incurred for one incident or in any one year is commonly called a/an insurance cap
Created by: Iteach4Docs



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