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MAP 114
week 1 exam
| Term | Definition |
|---|---|
| Coding | The process of reporting diagnoses and procedures as numeric and alphanumeric characters on the insurance claim |
| CMS | Administration within the Department of Health and Human Services (DHHS) |
| CPT | Coding system is used to report procedures and services on claims |
| Reimbursment | A health insurance claim is submitted to a requesting payer. |
| Documentation | Serves as a bases for coding. |
| ICD-10 CM | Classifaction system that was developed in the US; used to code and classify data from in and out patient records. |
| Government Program | Whom a health insurance is contracted with. (country) |
| Physcian | Whom a health insurance is contracted with.(office) |
| Third Party | Whom a health insurance is contracted with. (family friend or layer) |
| Deductable | Total amount of covered ed medical expenses a policy holder must pay each year out of pocket before the insurance company pays and benefits |
| Continuty of Care | The primary purpose of the patient record is to provide? |
| Electronic Health Record | Collection of patient information documented by a number of providers at different facilities. |
| PCP | Responsible for supervising and coordinating healthcare services for enrollees |
| Capitation | A provider accepts preestablished payments for services provided over time. |
| Enrollees | Are also called subscribers or policyholders |
| Prepaid | HMO provides healthcare services to voluntarily enrolled members on what basis. |
| Provider | A new patient has never recieved services from. |
| PPO | Managed care model (first) |
| POS | Managed care model (second) |
| HMO | Managed care model (third) |
| PPO | Manage care network for physcians and hospitals that contract with insurance companies and employers or organizations. |
| Aging Report | Helps determine whether a claim is for a parent or child. |
| Guarantor | Person responsible for paying charges. |
| Participating Provider | Higher out of pocket cost. (PAR) |
| Primary Insurance | Responsible for paying health insurance claims |
| Brithday Rule | Mother |
| Encounter Form | Record treated diagnoses and services renderd to the patient. |
| Payers | Who the claims submission form is sent to for processing. |
| Denial of Claim | if procedures are not medically necessary, out of network, and non-covered benefits. |
| Claims Adjunction | Involves comparing the claim to the payer edits. |
| Coordination of Benefits | Prevents one insurance carrier form paying what another insurance carrier payed. |
| 120 Days | The time after a insurance claim is consider delinquent. |
| Coinsurance | Is the percentage the patient pays for covered service after deductable has been met and the copayment has been paid |
| Medicare | States that providers must retain copies of any government insurance claim and all attachments filed for 5 years. |
| Litigation | A legal action used to recover a debt and usually a last resort for a medical practice. |
| Subpoena | Order of the court that requires a witness to appear at a particular time and place to appear. |
| Subpoena duces tecum | Requires documents to be produced in court. |
| One year | The length of time a signed authorized release of information form should be kept. |
| Release of Information | A form that releases information about the patient to whomever's name is on the form. |
| Civil Law | Is not Public Law |
| Depostion | Testimony under oath; taken outside of court sush as the physcian's office. |
| Fraud | Intentional deception or misrepresentation that results in an unauthorized payment. |
| Federal Register | A legal newspaper published every business day by the National Archives Administration (NARA) available in paper, mircrofish, and online. |
| HIPPA Abuse | Inconsistant with accepted sound medical business or fiscal practices which directly or indirectly results in unecessary cost to the program through unproper payemnt. |
| Release of Information | HIV and AIDS patient must sign this additional form. |
| Privacy Rights | Rights of an individual to keep their information from being discloused to others. |
| Coding Systems | ICD-10 CM and HCP-CS |
| Outpatient | Treated in a ambulatory setting. |
| Medical Necessity Criteria | A procedure or service is performed to treat a healthcare condition. |
| Complication | Diagnoses that is developed after outpatient care. |
| ICDM-10 CM Code | Procedures and services submitted on a claim are linked to this code. |
| CPT Modifiers | Clarify and/or Alters the meaning of services or procedures performed by providers. |
| Level II HCPCS | Any medical service and supplies not found in CPT. |
Created by:
nikidelaware
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