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Assisgnment of Benefits(4)
the provider receives reimbursement directly from the payer
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AOB
Assignent of Benefits
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Accept Assisgnment (4)
provider accepta as paymennt in full whatever is paid n the claime by the payer.
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Clearinghouse (4)
peerforms centralized claims processing for providers and health plans
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COB
Coordination of Benefits
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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.
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EOB (1)
Explanation of Benefits
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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)
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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.
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EMC (4)
Electronic Media Claim
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Electronic Mieda Claim (4)
electronic flat file format
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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
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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
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PAR (4)
Participating Porvider
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Participating Provider (4)
contract with a health insurance plan and accepts whatever the plan pays for procedures or services performed; in network
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NonPAR (4)
Nonparticipating Service Provder
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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
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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
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Patient Ledger
Patient Account Record
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Patient Account Record(4)
a computerized permanent reord of all financial transacrions between the patient and the practice
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DaySheet (4)
also called manual daily accounts receivale journal; chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day
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Copayment (2)
specified dollar amount for each medical visit or service paid to healthcare provider
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Coinsurance
the percentage of costs a patient pays for service
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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
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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
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CMS
the administrative agency within the federal department oof Health and Human Services
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HCPCS
- Healthcare common procedure coding system
- -2 levels CPT (procedures and services in and out-patients/professional services for in-patients)
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MCO
Managed Care Organization
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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
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capitation
fixed payments for providing services over a period of time (usually one year)
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GateKeeper (PCP)
- primary care providerfor essential healthcare services at the lowest possible cost, avoiding nonessential care, and reffering patients to specialists
- -Refferals
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Gag Cluase
(PROHIBITED) prevent providers from discussing all reatment options with patients, whether or not the plan would provide reimbursement for services
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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
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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
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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
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Place of Service
location were health care is provided; a two-digit location code is required by medicare
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Birthday Rule
states that the policy holder whose birth month and day that is first in a calendar year determines the primary coverage.
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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
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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
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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
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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)
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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
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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
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