Study Guide
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| Renewable Provision Policy | Grants the insurer the right to cancel the policy at any time.
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| Optionally Renewable Policy | The insurer right to refuse to renew the policy on a specific date (anniversary date.
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| Conditionally Renewable Policy | The insurer has limited right to refuse to renew a health insurance policy.
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| Guaranteed Renewable Policy | The policy renews as long as the premium is paid.
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| Non-cancelable Policy | Insurer cannot increase the premium unless the insurer has reached the age specified in the contract.
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| Blue Cross/Blue Shield | Non-profit policy providing prepaid health care service.
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| CHAMPUS Civilian Health&Medical Program of Uniformed Services | Used for active duty and family.
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| CHAMPVA Civilian Health&Medical Program of Veteran Administration | Used for veterans and disable veterans.
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| CMP Competitive Medical Plan | Medicare benefits enrolled into managed care plans
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| EPO Exclusive Provider Organization | Uses services of limited network of provides.
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| Assignment | Transfer of right for payment from patient to physician.
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| Indemnity | Benefits paid to the insurer
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| Premium | Payment required to be paid to keep insurance current
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| Deductible | The amount the insurer pays before the policy
pays.
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| Exclusion | Certain benefits or illnesses not covered by policy.
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| Carrier | The insurance company.
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| Statue of Limitations | An insurer has 3yrs to bring legal action to a claim.
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| Preauthorization | Type of approval required; prior to procedure.
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| Precertification | Type of approval to determine if treatment is covered.
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| HCFA 1500 Health Insurance Claim Form | Insurance claim is submitted is submitted on this form.
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| Eponyms | Represents disease names and should not be used in billing.
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| Dingy Claims | The claim is held until chgs within the system allows payment
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| Dirty Claims | Claims with errors that manual processing.
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| Rejected Claims | Claims that require an investigation.
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| Clean Claims | Claims submitted with all important information in a timely matter(60days).
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| How long are medical records for Medicare recipients kept? | 7years
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| How long are medical records for Deceased recipients kept? | 5years
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| How long are medical records for Radiology injuries recipients kept? | 20-30years after radiation exposure
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| How long are medical records for Active recipients kept? | Indefinite retention
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| Changing dates of service is an example of? | Fraud
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| Billing for services not rendered is an example of? | Fraud
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| Up coding is an example of? | Fraud
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| Claims for services not medical necessary is an example of? | Abuse
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| Excessive charges for services or supplies is an example of? | Abuse
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| Billing Medicare beneficiaries at a higher rate is an example of? | Abuse
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| Breaching assignment agreement is an example of? | Abuse
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| Altering fees on a claim form to obtain higher payment is an example of? | Fraud
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| All records are confidential except? | 1)Signed authorization to release info
2)Workers compensation cases
3)Pt is Suing someone
4)Pt records are subpoenaed
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| What type of information should not faxed? | a)HIV status
b) Drug and Alcohol Treatment
C)Sexually Transmitted Diseases
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| What happens when a Pt. misses an appointment? | 1)Notated in medical record.
2)Letter is mail out to Pt. notifying the Pt. of missed appt.
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| When can a patient terminate their contract with the doctor? | At anytime
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| How can a physician terminate the patients contract? | In writing with a return signature card.
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| How do you abstract a medical record? | 1)Provide only authorized information to agents
2)Obtain patient signature for release
3)Agent must pay for time and effort
4)Do not release HIV info, even if Pt authorize it.
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| What is the correct procedures for copying a record for an authorized agent? | a)Allow Doctor to review prior to copying
b)Agent must make an appt. to copy record
c)Agent must pay for supplies and equip.used
d)Record does not leave the office
e)Must have a signed release.
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| Malpractice | Unreasonable lack of skill that results in an injury.
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| What are some methods insurance claims is submitted? | Optically scanned(if not optically scanned check thoroughly for tampering, Manual, Electronic,Faxed
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| Identify who is the primary holder in dual coverage; give two examples:` | 1)Spousal: Policy is always primary for the holder
2)Children: Parents who birth month comes first on the calendar.
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