Medical Insurance: An Integrated Claims Approach Process
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| *What are the 3 parts for Processing encounter for billing purposes | show 🗑
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| show | Someone who has not received services from the provider in a particular practice withing the past 3 years.
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| show | This patient has scene the provider withing the past 3 years.
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| *What is a referring physician? | show 🗑
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| *MCO | show 🗑
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| show | 1. Physician must see patient in a short period of time after patient calls for apt.
2. Emergencies need to be handled in the office instead of the ED.
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| Participating Provider (PAR) | show 🗑
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| show | An Out-of-Network physician not contracted with an insurance company.
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| show | Subscriber, Insured, or Guarantor
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| Patient Info./Reg. Form | show 🗑
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| *What does it mean by Matching Patient Name? | show 🗑
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| Direct Provider | show 🗑
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| Do Indirect Providers have to secure additional acknowledgment? | show 🗑
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| show | Is a Unique # that identifies the patient.
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| Why is good communication with patients so essential? | show 🗑
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| show | So that you know what co-payments, precertification, referral requirements, and non-covered services are in a plan.
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| *How do you help secure preauthorization? | show 🗑
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| *What does it mean to process a patient financial agreement? | show 🗑
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| *Do you bill Supplemental Insurance Plans before or after you have received payment from the primary? | show 🗑
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| *What is the Birthday Rule? | show 🗑
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| show | The plan that pays first.
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| *What are encounter forms? | show 🗑
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| What are encounter forms called in hospitals? | show 🗑
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| What is charge capture? | show 🗑
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| show | 1.Charges
2.Payments
3.Adjustments
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| What does the Collection of Time-of-Service payment entail? | show 🗑
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| *Direct Provider | show 🗑
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| show | Authorization by a policyholder that allows a payer to pay benefits directly to a provider.
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| *New Patient | show 🗑
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| *Secondary Insurance | show 🗑
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| *Encounter Form | show 🗑
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| show | A patient who has received professional services from a provider, or another provider in the same practice with the same specialty, in the past 3 years.
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| show | Policyholder, guarantor, or subscriber
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| show | A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
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| show | Document given to a patient who makes a payment.
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| show | Form completed by patients that summarizes their demographic and insurance information.
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| *T/F The HIPAA Health Care Claims or Equivalent Encounter Information/Coordination of Benefits transaction is used for both health care claims and coordination of benefits b/c secondary payer information goes along with the claim to the primary payer. | show 🗑
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| show | False
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| show | True
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| show | True
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| *T/F The provider does not need authorization to release a patient's PHI for treatment, payment, or operations purposes | show 🗑
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| *T/F The HIPAA Eligibility for a Health Plan transaction may be used to determine a patient's insurance coverage. | show 🗑
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| *T/F Patient's dates of birth should be recorded using all four digits of the year of birth | show 🗑
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| *T/F Patient's insurance benefits are usually verified after provider encounters. | show 🗑
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| show | False
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| show | True
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| *nonPAR | show 🗑
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| *COB | show 🗑
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| show | Participating Provider
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| show | New Patient
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| *EP | show 🗑
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| show | B. The # on the patient's insurance card
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| *If a health plan member receives medical services from a provider who does not participate in the plan, the cost to the member is: | show 🗑
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| show | A. The patient's personal information, employment data, and insurance information.
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| show | C. Secondary
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| show | D. referral and authorization
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| show | C. both A and B
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| show | A. Billing
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| show | D. both A and B
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| show | B. Co-pays, non-covered or overlimit fees, charges of nonparticipating providers, and charges for self-pay patients
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| *The Tertiary insurance pays: | show 🗑
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Created by:
crazedsmyle
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