Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Chapter 01
Health Insurance Specialist Career
| Question | Answer |
|---|---|
| health insurance claim | documentation that is electronically or manually submitted to an insurance plan requesting reimbursement for health care procedures and services provided (e.g., CMS-1500 and UB-04 claims). |
| hold harmless clause | policy that the patient is not responsible for paying what the insurance plan denies. |
| health care provider | physician or other health care practitioner (e.g., physician’s assistant). |
| Centers for Medicare and Medicaid Services (CMS) | formerly known as the Health Care Financing Administration (HCFA); an administrative agency within the federal Department of Health and Human Services (DHHS). |
| Coding | process of reporting diagnoses, procedures, services, and supplies as numeric and alphanumeric characters (called codes) on the insurance claim. |
| Codes contain alphanumeric and numeric characters | e.g., A01.1, 0DTJ0ZZ, 99202, K0003 |
| Diagnoses are documented conditions or disease process | (e.g., hypertension) |
| Procedures are performed for diagnostic | e.g., lab test |
| therapeutic | (e.g., cholecystectomy) |
| International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) | coding system used to report diagnoses and conditions, such as diseases and injuries, along with other reasons for inpatient and outpatient encounters |
| International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS) | coding system used to report procedures and services on inpatient hospital claims |
| Healthcare Common Procedure Coding System (HCPCS, pronounced “hick picks”) | which currently consists of two levels: |
| Current Procedural Terminology (CPT) | coding system published by the American Medical Association (AMA) that is used to report procedures and services performed during outpatient and physician office encounters |
| HCPCS Level II codes (or national codes) | coding system published by CMS that is used to report procedures, services, and supplies not classified in CPT |
| Medical necessity | involves linking every procedure or service code reported on an insurance claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) |
| Coders | applies working knowledge of coding systems, coding conventions and guidelines, government regulations, and third-party payer requirements |
| Health insurance specialists | person who reviews health-related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider; see also reimbursement specialist. |
| claims examiner | employed by third-party payers to review health-related claims to determine whether the charges are reasonable and medically necessary based on the patient’s diagnosis. |
| medical assistant | employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly. |
| Health information technicians | professionals who manage patient health information and medical records, administer computer information systems, and code diagnoses and procedures for health care services provided to patients. |
| internship | nonpaid professional practice experience that benefits students and facilities that accept students for placement; |
| independent contractor | “a person who performs services for another under an express or implied agreement and who is not subject to the other’s control, or right to control, of the manner and means of performing the services. |
| professional liability insurance | provides protection from liability as a result of errors and omissions when performing their professional services; also called errors and omissions insurance. |
| Bonding Insurance | an insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee. It protects the financial operations of the employer. |
| Medical malpractice insurance | a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment. |
| Business Liability Insurance | protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising. |
| Property Insurance | protects business contents (e.g., buildings and equipment) against fire, theft, and other risks. |
| Workers’ Compensation Insurance | insurance program, mandated by federal and state governments, that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders. |
| professionalism | conduct or qualities that characterize a professional person. |
Created by:
Amaya122000