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Flashcards in Health Insurance & Billing Deck (21)
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1

Centers for Medicare and Medicaid Services -basic standard claim form used by health care professionals to request reimbursement for services provided to patients

CMS-1500

2

an itemized form of services submitted to insurance carriers for reimbursement of rendered services -a CCMA would also use this form to check patients out after an office visit

Encounter Form (Superbill)

3

allows a patient access to his or her own medical records and allows the patient control over to whom those records are released

Release of Information Form

4

managed care organization of providers, hospitals and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients

Preferred Provider Organization (PPO)

5

a federal and state program that helps with medical costs for some people with limited income and resources (the medically needy)

Medicaid

6

federal health insurance program that generally covers those over 65, the disabled and those with end-stage renal disease -considered an entitlement because most of those in the system have paid into the system through payroll tax

Medicare

7

healthcare for military personnel and their dependents to receive care from civilian providers at the expense of the federal government

Tricare

8

wage replacement and medical benefits for those injured on the job

Workers' Compensation

9

waiver of liability; a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service (the patient will then be responsible for paying the bill)

Advance Beneficiary Notice (ABN)

10

an amount a policyholder is financially responsible for according to their insurance policy the policy holder must meet a specified amount before the insurance company will pay their portion

Coinsurance

11

a specified sum of money based on the patient's insurance policy benefits due at the time of service

Copay

12

specific amounts of money a patient must pay out-of-pocket before the insurance carrier begins paying for services in a calendar year

Deductible

13

a statement detailing what services were paid, denied or reduced in payment by the patient's insurance company

Explanation of Benefits (EOB)

14

a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary

Preauthorization

15

the process of obtaining eligibility, certification or authorization and collecting information from the health plan prior to impatient admissions and selected ambulatory procedures and services

Precertification

16

the process of directing or redirecting to a medical specialist or agency for definitive treatment

Referral

17

before you provide care, it is important to confirm how a patient will pay for services; equally important to verify a patient's insurance eligibility before you provide any care

Verification of Eligibility

18

Current Procedural Terminology

CPT

19

International Classification of Diseases -each diagnostic procedural code allows for submission of services for reimbursement from insurance companies and to provide statistical data for research studies

ICD

20

3-7 characters used -First character: main term when searching in the alphabetical index -Second/Third Characters: numeric codes -Fourth, Fifth, Sixth or Seventh: being either alphabetic or numeric

ICD Codes

21

indicates one procedure was used multiple times on a patient

Modifier