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Completa
Health Insurance & Claims Chapter 2
| Question | Answer |
|---|---|
| Prospective payment system used to calculate reimbursement for outpatient care according to similar clinical characteristics and in terms of resources required. | Ambulatory Payment Classification (APC) |
| Form used to submit outpatient insurance claims | CMS-1500 |
| Provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received. | copayment (copay) |
| Amount for which the patient is financially responsible before an insurance policy provides coverage. | deductible |
| Reimbursement for income lost as a result of a temporary or permanent illness or injury. | disability insurance |
| Health care coverage available through employers and other organizations. | group health insurance |
| Three or more health care providers who share equipment, supplies, and personnel, and divide income by a prearranged formula. | group medical practices |
| Mandates regulations that govern privacy, security, and electronic transactions standards for health care information. | Health Insurance Portability and Accountability Act of 1996 (HIPAA) |
| Coverage for catastrophic or prolonged illnesses and injuries. | major medical insurance |
| Cost-sharing program between the federal and state governments to provide health care services to low-income Americans. | Medicaid |
| Reimburses health care services to Americans over the age of 65 and patients with End-stage renal disease (ESRD). | Medicare |
| Federal legislation that expanded the Medicare and Medicaid programs. | Omnibus Budget Reconciliation Act of 1981 (OBRA) |
| Designed to help individuals avoid health and injury problems. | preventive services |
| Issues predetermined payment for services | prospective payment system (PPS) |
| Performs utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries. | quality improvement organization (QIO) |
| Based on data collected from resident assessments, using data elements called the Minimum Data Set, or MDS, and relative weights developed from staff time data. | Resource Utilization Groups (RUGs) |
| Payment system that reimburses physicians' practice expenses based on relative values for three components of each physician's services; physician work, practice expense, and malpractice insurance expense. | Resource-Based Relative Value Scale system (RBRVS) |
| Process of the third-party payer recovering health care expenses from the liable party. | subrogation |
| Who other than an insurance company administers health care plans and process claims, thus serving as a system of checks and balances for labor and management. | third-party administrator (TPA) |
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