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Chapters 3 and 7 Lecture


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"Other" claims
Medicare claims not considered "clean" claims, which require investigation or development on a prepayment basis are known as
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Optical Character Recognition (OCR)
a device (scanner) used across the nation in processing insurance claims
Medicare (M)
A nationwide health insurance program for persons age 65 years of age and older and certain disabled or blind persons regardless of income, administered by HCFA.
State Disability Insurance (SDI)
Insurance that covers off-the-job injury or sickness and is paid for by deductions from a person's paycheck.
Workers' compensation insurance (WC)
A contract that insures a person against on-the-job injury or illness. The employer pays the premium for his or her employees.
Coordination of Benefits
When a patient has more than one insurance policy, what statement includes the clause requiring insurance companies to coordinate the reimbursment of benefits to determine which carrier is going to be primary and secondary?
The Birthday Law
If both father and mother have the same birthday, the plan of the person who has had the coverage longer is the primary payer
Health maintenance organization (HMO)
The oldest of all prepaid health plans.
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Paper claim
Claims submitted on paper
Primary and Secondary
When two insurance policies are involved one is called WHAT and the other is called WHAT?
Disability income insurance
A form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease-not as a result of a work-related accident or condition
The physician-patients contract begins when
the physician accepts the patient and agrees to treat him or her
Patient information and Physician information
What are the two major sections on the CMS-1500 claim form
Health Insurance Claim Form (HICFA-1500) currently referred to as CMS-1500
April 1975 the AMA approved a "universal claim form" called the
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Individual Contract
Any insurance plan issued to an individual is called
Independent or individual practice association (IPA)
A type of HMO in which a program administrator contracts with a number pf physicians who agree to provide treatment to subscribers in their own offices.
Medicaid (MCD)
A federally aided, state-operated and -administered program that provides medical benefits for certain low-income persons in need of health and medical care.
An individual or organization protected in case of loss under the terms of an insurance policy
Consolidation Omnibus Budget Reconciliation Act of 1985 (COBRA)
Required by Federal Law that if an employee is laid off from a company with 20 or more workers, that group health insurance coverage be extended to the employee and his or her dependents for up to 18 months.
A three-option managed health care program offered to spouses and dependents of service personnel with uniform benefits and fees implemented nationwide by the federal government.
Patient information and Physician information
The Health Insurance Claim Form is divided into two major sections
Coordination of Benefits
If both mother and father have the same birthday, the plan of the person who has had coverage longer is the primary payer.
Not only whether a procedure is covered, but also to find out it is medically necessary
Electronic claim
Claims submitted to the insurance carrier via a central processing unit, tape diskette, direct data entry, direct wire, dial-in telephone, or personal computer via modem
Case Management Requirements Eligibility
Preauthorization: not only whether a procedure is covered, but also to find out it is medically necessary
The Civilian Heath and Medical Program of the Department of Veterans Affairs (CHAMPVA)
A program for veterans with total, permanent, service-connected disabilities or surviving spouses and dependents of veterans who died of service-connected disabilities.
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Coordination of Benefits
Prevents the duplication or overlapping of payments for the same medical expense

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