Module 3 Final Exam(Medical Billing and Coding)
Terms
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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____________________.
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CASE MANAGEMENT
- The review for appropriateness and necessity of care provided to patients, prior to the administration of care or retrospectively, is called_________________.
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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___________________.
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SUBMISSION - If a claim is found to contain all the data elements required for processing, it is known as a _______________claim.
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CLEAN - A procedure reported on a claim that is not included on the master benefit list will result in ______________ of the claim.
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DENIAL - Which type of HMO offers subscribers health care services b y physicians who remain in their individual office setting?
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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___________________.
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Accreditation - Which coding system is used to report procedures and services on physician office insurance claims?
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CPT AND HCPCS - Which is a government-sponsored health program that provides benefits to indigent patients?
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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_______________.
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DEDUCTIBLE
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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?
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OUTPATIENT - The specified percentage of charges the patient must pay to the provider for each service received or for each visit is the_________________.
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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________________________.
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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.
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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?
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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 ______________.
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GUARANTOR - The remittance advice has what name in the Medicare Program?
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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.
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100%
- A certificate issued by a military treatment facility stating that the facility cannot provide needed care is called the________statement.
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NONAVAILABILITY - A patient is seen by his surgeon for posoperative complications; any services provided are:
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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:
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DIAGNOSIS CODE POINTER (REFERENCE) NUMBER (CPT-CODE) - The unique identifier that CMS will assign to providers as part of HIPAA requirements is called the:
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NPI
NATIONAL PROVIDER IDENTIFICATION - Which character is entered in the boxes of Block 8 of the CMS-1500 claim to indicate patient status?
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X - What is reported in Block 24E of the CMS-1500?
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THE REFERENCE OR POINTER NUMBER - The type of health care that helps individuals avoid health and injury problems is:
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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_________________.
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GROUP PRACTICE