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CertReview6 3/29

Quiz 6

QuestionAnswer
patient responsibility The amount the patient owes
preauthorization The health plan is notified that a hospital stay or significant procedure is coming up, giving the plan the opportunity to determine if it is medically necessary and in case of an inpatient admission, how many days the patient most likely will stay
precertification A review that looks at whether the procedure could be performed safely but less expensively in an outpatient setting
predetermination A written request for a verification of benefits
preferred provider organization (PPO) Plan that allows patients to use physicians, specialist, and hospitals in plan's network
primary insurance Insurance that pays first, up to the limits of its coverage
prior approval number Number indicating that the insurance company has been notified and has approved services before they were rendered
Privacy Rule A HIPPA rule that establishes protections for the privacy of individual's health information
private-fee-for-service plan Plan that allows patients to go to any physician, other health care professional, or hospital as long as the providers agree to treat those patients
protected health information (PHI) Individually identifiable health information
provider-level adjustment reason code Codes that are not related to a specific claim
referral Written recommendations to a specialist
referring provider The physician or other licensed health care professional who requests a service for a patient
reimbursement Payment for services rendered from a third-party payer
remittance advice (RA) The report sent from the third-party payer to the provider that reflects any changes made to the original billing
remittance advice remark code (RARC) Code that explains the reason for a payment adjustment
revenue code Four-digit code that identifies specific accommodation, ancillary service, or billing calculation related to services on a bill
staff model HMO that provides hospitalization and physician services through its own staff
Stark Law Physicians are not allowed to refer patients to a practitioner with whom they have a financial relationship
Created by: sbogle
 

 



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