flashcardsforinsurancemidterm.txt

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flashcardsforinsurancemidterm.txt
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study for midterm!!! let me know if i let anything out monanorwood@gmail.com
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  1. Assisgnment of Benefits(4)
    the provider receives reimbursement directly from the payer
  2. AOB
    Assignent of Benefits
  3. Accept Assisgnment (4)
    provider accepta as paymennt in full whatever is paid n the claime by the payer.
  4. Clearinghouse (4)
    peerforms centralized claims processing for providers and health plans
  5. COB
    Coordination of Benefits
  6. Coordination of Benefits
    provision in group health policies that prevents multiple insurance from paying benefits covered other policies; provides a specific sequence when more than one policy covers the claim.
  7. EOB (1)
    Explanation of Benefits
  8. Explanation of Benefits (1)
    report that details the results of prcessing a claim (e.g.: payer reimbrses provider $80 on a submitted charge odf $100)
  9. RA
    Remittance Advise
  10. Remittance Advise (1)
    electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service (from date/tthru date), type of bill (TOB), charges, payment information, and reason and/or remark codes.
  11. EMC (4)
    Electronic Media Claim
  12. Electronic Mieda Claim (4)
    electronic flat file format
  13. Electronic Flat file fomat (4)
    series of fixed-length records (ex: 25 spaces for patient's name) submittted to payers to bill for healthcare services
  14. Encouter Form(4)
    financial record source document used by providers and oter personnel to record treated diagnoses and services rendered to the patient during the currrent encounter/Superbill
  15. PAR (4)
    Participating Porvider
  16. Participating Provider (4)
    contract with a health insurance plan and accepts whatever the plan pays for procedures or services performed; in network
  17. NonPAR (4)
    Nonparticipating Service Provder
  18. Nonpartcitpating Service Provider
    does not contrqaact with the insurance plan; patients who elect to receive care from nonPARs will incur higher out-of-pocket expenses
  19. Preexisting Condition (4)
    any medical conditin that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee's effective date of coverage
  20. Patient Ledger
    Patient Account Record
  21. Patient Account Record(4)
    a computerized permanent reord of all financial transacrions between the patient and the practice
  22. DaySheet (4)
    also called manual daily accounts receivale journal; chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day
  23. Copayment (2)
    specified dollar amount for each medical visit or service paid to healthcare provider
  24. Coinsurance
    the percentage of costs a patient pays for service
  25. Disability Inurance
    • -Reimbursement for income lost as a result of a temporary or permanent illness or injury
    • -General, does not pay for healthcare services
    • -Other insurance coverage is usually the primary to basic health coverage
  26. Liability Insurnce
    • covers loses to a third party caused by the insured, by an object owned by the insured or on premises owned by the insured
    • -Covers cost for:
    • medical care
    • lost wages
    • pain and suffering
    • --health insurance benefits mostly secondary to this insurance
  27. CMS
    the administrative agency within the federal department oof Health and Human Services
  28. HCPCS
    • Healthcare common procedure coding system
    • -2 levels CPT (procedures and services in and out-patients/professional services for in-patients)
  29. MCO
    Managed Care Organization
  30. Managed Care Organization
    • is responsible for the health of a group of enrollees and can be a health plan, hospital, physician group, or health system
    • -financed through capitation
    • -if service fee is less than set rate the physician keep the remainder as profit; if more the physician loses money
  31. capitation
    fixed payments for providing services over a period of time (usually one year)
  32. GateKeeper (PCP)
    • primary care providerfor essential healthcare services at the lowest possible cost, avoiding nonessential care, and reffering patients to specialists
    • -Refferals
  33. Gag Cluase
    (PROHIBITED) prevent providers from discussing all reatment options with patients, whether or not the plan would provide reimbursement for services
  34. Business Liability Insurance
    protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury (eg.: slander or libel, and false advertising
  35. Medical Malpractice
    Insurance is a type of liability in surance which cover physicians and other healthcare professionals for liability as to claims arising form patient treatment
  36. PPO
    • Preferred Provider Organization
    • network of providers contracted to insurance cmpanies, employers, or other organizations to provide health care to subscribers for a discounted fee
  37. POS
    Place of Service
  38. Place of Service
    location were health care is provided; a two-digit location code is required by medicare
  39. Birthday Rule
    states that the policy holder whose birth month and day that is first in a calendar year determines the primary coverage.
  40. Which was the first commercial insurance company in the United Stated to provide private healthcare coverage for injuries not result in in death?

    a. Baylor University Healthplan
    b. Blue Cross/Blue Shield Association
    c. Franklin Health Assurance Company
    d. Office of Workers' Compensation
    • c. Franklin Health Assurance Company
  41. The Blue Shield concept grew ut of the lumber and mining camps of the _____ region and the turn of the century.

    a. Great Plains
    b. New England
    c. Pacific Northwest
    d. Southwest
    • b. New England
  42. Third-party administrators TPA's administer healthcare plans and process claims, serving as a:

    a. clearinghouse for data submitted by government agencies
    b. Medicare administrative contractor MAC for business owner
    c. system of checks and balances for labor and management
    d. third-party payer (ins co) for employers
    • c. system of checks and balances for labor and management
  43. Major medical insurance provides coverage for ____ illnesses and injuries, incorporating large dedictibles and lifetime maximum amounts

    a. acute care (short term)
    b. catastrophe or prolonged
    c. recently diagnosed
    d. work-related
    • a. acute care (short-term)
  44. The Tax Equityand Fiscal Responsiblilty Act of 1982 (TEFTRA) enacted the __ prospective payent system (PPS)

    a. ambulatory payment classifications
    b. diagnosis-related groups
    c. fee-for-service reimbursement
    d. resource-based relative value scale system
    • b. diagnosis-related groups
  45. A ______ is responsible for supervising and coordinating healthcare services for enrollees

    a. case manager

    b. primary care provider
    c. third party administrator
    d. utilization review monitor
    • b. primary care provider

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