An unexpected, unplanned event that may involve injury is
An accident
Specific conditions listed in an insurance policy will not pay as
Exclusions
What document is sent by private insurance carriers to detail amounts paid or denied on an insurance claim
Explanation of benefits
Periodic payments made to keep an insurance policy in force are
Premiums
An illness or injury that prevents an individual from performing all major duties of his or her occupation or from engaging in any other type of work is a
Total Disability
Terms in a group insurance policy that allow the insured to continue the same or lesser coverage under an individual policy is a
Conversion privilege
An insurance policy is a legally enforceable
Contract
An injury or illness that occurred before the issuance of a health insurance policy is a
Preexisting condition
Claims may be received, edited, and distributed electronically to insurance companies through a central
Clearing house
Which of the following is a method of payment in which the physician is paid a set amount for each patient enrolled regardless of services provided
Capitation
The process of finding out if a service or procedure is covered under a patient's insurance policy
Precertification
The process of finding out the maximum dollar amount that an insurance company will pay for a particular service or procedure
Predetermination
A voluntary prescription drug coverage plan falls under which part of the medicare program
Part D
Hospital insurance benefits are provided under which part of the medicare program
Part A
The hospital benefits program that covers dependents of men and women in the military is
TRICARE
Federal legislation that requires employers offer extended group health insurance benefits to employees and dependents affected by job loss or other life events is called
COBRA
The National Provider Identifier (NPI) number serves as a unique identifier for physicians who
Submit health insurance claims
Which type of policy is available from private insurance companies and regulated by the federal government to supplement medicare coverage
Medigap
A feature of electronic billing systems that reviews claim data and identifies inconsistencies or missing information before the claim is submitted is the
Claim scrubber
Accurate diagnostic and procedural codes must be included as part of
Health insurance claims
If a valid claim has not been paid after multiple inquiries and or a denial has been received, what may be filed with the insurance company
appeal
what is a procedure that is done by insurance companies to avoid duplicate payments due to benefits provided by more than one policy
coordination of benefits
When a patient provides written authorization for a physician or health care facility to receive payment from a third party (insurer) for services, this is known as
Assignment of benefits
What information must be copied from a patient's insurance card
The front and back of the card
When an insurance company determines that a particular service or procedure is appropriate based on standards of prudent care this is establishing
Medical necessity
Under which type of managed care plan will the cost of services be covered only if the patient receives care from a participating physician
HMO
a complaint of a physicians charges and payments made by an insurance company for specific services over a period of time is the physicians..?
profile
which type of claim contains complete info but its content is to illogical or incorrect
invalid claim
under which type of managed care plan can enrollees obtain services for nonparticipating physicians and pay a higher percentage of the costs
PPO
which type of claim is held in suspense by an insurance company for review or because additional info is needed before a payment determination can be made
pending
according to the patient protection and affordable care act which is designed to insure an additional 32 mill Americans, everyone must purchase health insurance or face a 695$$ annual fine by the year
2014
dependents of the insured are who
spouses, children and domestic partners
a HDHP is a
insurance health plan with a high deductible
health care reform assures that there will no longer be
limitations on coverage, limits for lifetime max benefits, preexisting clauses
with health care reform, parents will be able to keep adult children on their polices until
26
under which type of managed care plan can physicians see capitated managed care patients and private pay PT's and maintain their own offices
IPA
medicaid is a health assistance program sponsored
state, federal + local governments
the medicaid program is generally for who
low income, needy individuals
with health care reform, medicare patient's who now belong to medicare advantage plans that earn higher income will soon
no longer qualify for medicare
medicare physicians and practitioners can "opt-out" of the medicare program for how long
2 years
When submitting electronic claims it is referred to as
ECT
What is the statement called that is sent to a Medicare patient summarizing the disposition of a claim in laymen's terms
Medicare summary notice
Adjudication
Determination of payment for an insurance claim
Deductible
Amount the insured must pay in a calendar year before policy benefits begin
Eliminations Period
Period of time after the onset of a disability for which no benefits will be paid
Exclusions
Hazards, perils, or conditions listed in an insurance policy for which the company will not pay
Limitations
Exceptions or reductions to coverage as outlined in a policy
Dependents
The spouse and/or children of the primary insured
Copayment
Cost sharing in which an insured patient pays a designated amount at the time of service
Coinsurance
Cost-sharing in which an insured patient assumes a percentage of the cost of covered services
Claim
Request for payment under an insurance contract
A Medicare patient's signature on an Advance Beneficiary Notice must be obtained
For all services medicare does not deem medically necessary
A signed consent to release medical information for treatment, payment, and health care operations
Is no longer mandated by HIPAA
The "birthday rule" helps to determine the plan when
A child is covered by both parents
To supplement Medicare, the Department of Defense offers
TRICARE for life
State disability insurance is offered in what states
California, Hawaii, NJ, NY, Rhode Island, & Puerto Rico
Which type of claim had been discarded by an insurance company's system because of technical errors and may be returned to the provider
rejected claims
when examining a medicare card, which had been presented for services in a physicians office, be sure the patient has part _____ coverage
B
to contain costs and prosecute cases of medicare and medicaid fraud, what law did the government pass?
civil monetary penalties law
a patient having both medicare and medicaid is referred to as
medi/ medi case
what is the acronym used when another payer is primary to medicare
MSP
eligibility for a tricare patient is verified by using
the VRU system + the tricare website
for tricare patient, a nonavailability statement is needed when a PT lives within a hospitals zip code area and
non emergency care is not available
denied claim
claim payment rejected because of a technical error or payment policy issue
dirty claim
claim submitted with errors may require manual processing
incomplete claim
medicare claim that contains complete, valid info but is illogical or incorrect
pending claim
claim held in review
rejected claim
claim discarded by the system due to technical errors
suspended claim
claim held by ins. co. as pending because of error or additional info needed (similar to pending)
Major Medical
Insurance policy designed to cover medical expenses resulting from injury or catastrophic or prolonged illness
Clean Claim
Claim submitted within the program time limit containing all necessary data to process and pay
Waiver
Attachment to a policy that excludes certain illnesses or disabilities
Premium
Payment made periodically to keep an insurance policy inforced
Usual, customary, and reasonable
Physician charge profiles determine these rates
Third Party Payers
Private insurance companies or government funded health plans
Total Disability
Illness or injury that prevents an individual from performing the major duties of his/her specific occupation
Temporary Disability
Illness or injury that prevents an individual from performing the major duties of his/her occupation for a limited time period
Preexisting Condition
Anything that was treated before the policy was issued
Preauthorization
Obtaining advance approval from an insurance carrier for a service or procedure to be performed
Partial Disability
Illness or injury that prevents an individual from performing one or more of the functions of a regular job
Permanent Disability
Illness or injury that prevents an individual from performing all the functions of a regular job
Invalid Claim
Medicare claim that contains complete, valid information but is illogical or incorrect