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Glossary of Module 3 Final Exam(Medical Billing and Coding)

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The process of developing patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner is called____________________.



CASE MANAGEMENT




The review for appropriateness and necessity of care provided to patients, prior to the administration of care or retrospectively, is called_________________.



UTILIZATION MANAGEMENT (UM)
OR
UTILIZATION REVIEW






In the development of a claim, data transmitted electronically or manually to payers or clearinghouses for processing is called claims___________________.



SUBMISSION


If a claim is found to contain all the data elements required for processing, it is known as a _______________claim.



CLEAN


A procedure reported on a claim that is not included on the master benefit list will result in ______________ of the claim.



DENIAL


Which type of HMO offers subscribers health care services b y physicians who remain in their individual office setting?



INDEPENDENT PRACTICE ASSOCIATION


If a plan allows enrollees to seek care from non-network providers, what effect will this have on the enrollee who sees a non-network provider? The enrollee will:
Pay Higher out-of-pocket expenses.
The voluntary process that a health care facility or organization undergoes to demonstrate that it has met requirements beyond those required by law is called___________________.




Accreditation



Which coding system is used to report procedures and services on physician office insurance claims?



CPT AND HCPCS


Which is a government-sponsored health program that provides benefits to indigent patients?



MEDICAID




The specified amount of annual out-of-pocket expenses for covered health care services that the insured must pay annually for health care is called the_______________.



DEDUCTIBLE





The standard claim developed by CMS and is used to report procedures and services delivered by physicians is called the______________.



CMS-1500


The ambulatory payment classification prospective payment system is used to reimburse claims for what services?



OUTPATIENT


The specified percentage of charges the patient must pay to the provider for each service received or for each visit is the_________________.



CO-PAYMENT




When the provider is required to receive as payment in full whatever amount the insurance reimburses for services, the provider is agreeing to________________________.



ACCEPT ASSIGNMENT


The rule stating that the policyholder whose birthday month and day occur earlier in the calendar year holds the primary policy for dependent children in the _______________ rule.



BIRTHDAY


When a provider performs a procedure for which no CPT or HCPCS level II code is available, what must be provided to the payer?



SPECIAL REPORT
(SUPPORTING DOCUMENTATION)



The person responsible for paying the charges for services rendered by the provider is the ________________.
The person responsible for paying the charges for services rendered by the provider is the ______________.



GUARANTOR


The remittance advice has what name in the Medicare Program?



PROVIDER REMITTANCE NOTICE
(PRN)



A BCBS special accidental injury rider covers ________percent of nonsurgical care sough and rendered within 24 to 72 hours of the accidental injury.



100%




A certificate issued by a military treatment facility stating that the facility cannot provide needed care is called the________statement.



NONAVAILABILITY


A patient is seen by his surgeon for posoperative complications; any services provided are:


IDENTIFIED ON THE CMS-1500 CLAIM WITH A 5 DIGIT MODIFIER.

The diagnosis code reported in item 1 BLOCK 21, of the CMS-1500 claim is the:


DIAGNOSIS CODE POINTER (REFERENCE) NUMBER (CPT-CODE)

The unique identifier that CMS will assign to providers as part of HIPAA requirements is called the:


NPI
NATIONAL PROVIDER IDENTIFICATION


Which character is entered in the boxes of Block 8 of the CMS-1500 claim to indicate patient status?



X


What is reported in Block 24E of the CMS-1500?



THE REFERENCE OR POINTER NUMBER


The type of health care that helps individuals avoid health and injury problems is:



PREVENTIVE


Payment for medical treatment of an injury will be denied by the liability payer if:
IF IT IS DETERMINED THAT THERE WAS NO THIRD PARTY NEGLIGENCE.
When three or more doctors deliver health care and make joint use of equipment, supplies, and personnel, this is called a_________________.



GROUP PRACTICE


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