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key terms

exercise slides 32-33

QuestionAnswer
National Committee for Quality Assurance (NCQA) provides guidelines on how facility selects providers to joint their organization and requires that the credentials of all providers be renewed every 2 years to make certain they remain professionally competent.
National Provider Identifier (NPI) was established as a standardized identifier for all health care providers to utilize when submitting a claim or other transactions related to health care services.
Office of the Inspector General (OIG) performs audits and investigates any potential fraudulent activities to protect the monies and enrollees under the programs.
Physician employees Physicians who are employed by the hospitals
Physician’s order Before the patient may be admitted to an inpatient facility or receive any services, the physician must request specific services.
Professional charge The physician will bill/code for this portion of the electrocardiogram
Protected health information (PHI) privacy as it relates to patient health information
Provider-based clinic a department of the hospital provides outpatient services.
Referring physician The physician who "refers" the patient for admission
Technical charge The equipment, technician, and disposable supplies that are necessary to perform the test.
Third-party contract refers to an agreement between the three parties mentioned.
Utilization review (UR) department that ensures that all of the health services provided to the patient during the admission are medically necessary and provided in an appropriate setting, and thus are reimbursable by the patient's insurance carrier.
Utilization Review Accreditation Commission (URAC) is to ensure quality and accountability of health care organizations, especially in the area of managed care.
Created by: mariaparra
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