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CertReview5 3/24

Quiz 5

medical necessity The medical documentation needed for a particular medical intervention
Medicare Administrative Contractor (MAC) Processes Medicare Parts A and B claims from hospitals, physicians, and other providers
Medicare Advantage (MA) Combined package of benefits under Medicare Part A and B that may offer extra coverage for services such as vision, hearing, dental, health and wellness, or prescription drug coverage
Medicare Federally funded health insurance provided to people age 65 or older, people younger than 5 who have certain disabilities, and people of all ages with end-stage kidney disease. Funded and administered at the national level
Medicare Part A Provides hospitalization insurance to eligible individuals
Medicare Part B Voluntary supplemental medical insurance to help pay for physicians' and other medical services, and medical-surgical supplies not covered by medicare part A
Medicare Part D A plan run by private insurance companies and other vendors approved by Medicare
Medicare specialty plan Plan that provides focused, specialized health care for specific group of people, such as those who have both Medicare and Medicaid, live in a long-term care facility, or have chronic medical conditions
Medicare Summary Notice (MSN) Document that outlines the amounts billed by the provider and what that patient must pay the provider
Medigap A private health insurance that pays for most of the charges not covered by parts A and B
modifier Additional information about types of services, and part of valid CPT or HCPCS codes
morbidity The number of cases of disease in a specific population
mortality The incidence of death in a specific population
MS-DRG grouper Software that helps coders assign the appropriate Medicare severity diagnosis-related group based on the level of services provided, severity or illness or injury, and other factors
National Provider Identifier (NPI) Unique 10-digit code for providers required by HIPPA
Network model HMO that contracts with two or more independent practices
Notice of Exclusion from Medicare Benefits Notification by the physician to a patient that a service will not be paid
ordering provider A physician or other licensed health care professional (e.g., physician assistant, nurse practitioner) who prescribes services for a patient
out-of-network Not contracted with the health plan
out-of-pocket maximum A predetermined amount after which the insurance company will pay 100% of the cost of medical services
Created by: sbogle



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