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Medical Billing/Code
Study Guide
Term | Definition |
---|---|
Renewable Provision Policy | Grants the insurer the right to cancel the policy at any time. |
Optionally Renewable Policy | The insurer right to refuse to renew the policy on a specific date (anniversary date. |
Conditionally Renewable Policy | The insurer has limited right to refuse to renew a health insurance policy. |
Guaranteed Renewable Policy | The policy renews as long as the premium is paid. |
Non-cancelable Policy | Insurer cannot increase the premium unless the insurer has reached the age specified in the contract. |
Blue Cross/Blue Shield | Non-profit policy providing prepaid health care service. |
CHAMPUS Civilian Health&Medical Program of Uniformed Services | Used for active duty and family. |
CHAMPVA Civilian Health&Medical Program of Veteran Administration | Used for veterans and disable veterans. |
CMP Competitive Medical Plan | Medicare benefits enrolled into managed care plans |
EPO Exclusive Provider Organization | Uses services of limited network of provides. |
Assignment | Transfer of right for payment from patient to physician. |
Indemnity | Benefits paid to the insurer |
Premium | Payment required to be paid to keep insurance current |
Deductible | The amount the insurer pays before the policy pays. |
Exclusion | Certain benefits or illnesses not covered by policy. |
Carrier | The insurance company. |
Statue of Limitations | An insurer has 3yrs to bring legal action to a claim. |
Preauthorization | Type of approval required; prior to procedure. |
Precertification | Type of approval to determine if treatment is covered. |
HCFA 1500 Health Insurance Claim Form | Insurance claim is submitted is submitted on this form. |
Eponyms | Represents disease names and should not be used in billing. |
Dingy Claims | The claim is held until chgs within the system allows payment |
Dirty Claims | Claims with errors that manual processing. |
Rejected Claims | Claims that require an investigation. |
Clean Claims | Claims submitted with all important information in a timely matter(60days). |
How long are medical records for Medicare recipients kept? | 7years |
How long are medical records for Deceased recipients kept? | 5years |
How long are medical records for Radiology injuries recipients kept? | 20-30years after radiation exposure |
How long are medical records for Active recipients kept? | Indefinite retention |
Changing dates of service is an example of? | Fraud |
Billing for services not rendered is an example of? | Fraud |
Up coding is an example of? | Fraud |
Claims for services not medical necessary is an example of? | Abuse |
Excessive charges for services or supplies is an example of? | Abuse |
Billing Medicare beneficiaries at a higher rate is an example of? | Abuse |
Breaching assignment agreement is an example of? | Abuse |
Altering fees on a claim form to obtain higher payment is an example of? | Fraud |
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 |
What type of information should not faxed? | a)HIV status b) Drug and Alcohol Treatment C)Sexually Transmitted Diseases |
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. |
When can a patient terminate their contract with the doctor? | At anytime |
How can a physician terminate the patients contract? | In writing with a return signature card. |
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. |
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. |
Malpractice | Unreasonable lack of skill that results in an injury. |
What are some methods insurance claims is submitted? | Optically scanned(if not optically scanned check thoroughly for tampering, Manual, Electronic,Faxed |
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. |