Chapter 3 : Insurance In The Medical Office.

A (n) ______is a patient that has not been seen by the provider within the past three years.

New patient

A (n) ______is patient who has been seen a provider within the past three years.

Established patient

NP is the abbreviation for __________.

New Patient

EP is the abbreviation for __________.

Established Patient

Which of the following is not a type of information that is important to gather when a patient is new to the practice ?

License plate number

A ______is the physician who refers a patient to another physician.

Referring physician

In a managed care organization, a group of providers is called ________.

Network

A provider who agrees to provide medical services to a payer's policyholders according to a contract is called _________.

PAR

PAR is the abbreviation for _________.

Participating provider

A (n) ______is a provider who does not join a particular health plan.

Nonparticipating provider

NonPAR is the abbreviation for _______.

Nonparticipating provider

A provider that does not have a participation agreement with a plan is _________.

Out-of-network

A form that includes a patient's personal, employment, and insurance company data is called _______.

Patient information form

The policyholder or subscriber to a health plan or policy is called ________.

Insured

Another term for the insured is _________.

Subscriber

A (n) _______is a person who is the insurance policyholder for a patient.

Guarantor

_________is a statement signed by the patient allowing benefits to be paid directly to the provider.

Assignment benefits

On a patient insurance card,group identification number is __________.

Used to identify the memeber's employer

On a patient insurance card, the plan codes are used for ___________.

Claims submissions when medical services are rendered out-of-state

On a patient's insurance card,the number used to identify each plan member is the _________.

Identification Number

Under the HIPAA Privacy Rule, under what conditions can a provider release patients' PHI without prior authorization ?

Treatment, payment, and health care operations (TPO) purposes

__________states that the patient has read the privacy practices and understands how the provider intends to protect the patient's rights to privacy under HIPAA.

Acknowledgment of Receipt of Notice of Privacy Practices

In the practice management program (PMP) a unique number that identifies a patient is called_________.

Chart number

When an established patient shows up for his or her appointment,what is the most important question the front desk staff member should ask ?

If any pertinent personal or insurance information has changed

A ________ is set up in the provider's practice management program when a patient's cheif complaint for an encounter is different from the previous cheif complaint.

New number

Which of the following is not a staep to establishing financial responsibility for an established patient ?

Determine if the patient has been out of the country in the past 90 days

HIPAA X12N 270/271 is ________.

HIPAA Eligibility for a Health Plan electronic transction form

To be paid for services, medical practices need to establish financial responsibility and the first step is ____.

Verify patients eligibility for benefits

When an eligibility benefits transaction (HIPAA 270) is sent the computer program assigns a unique number to the inquiry called _________.

Trace number

_________is an identifying code assigned when preauthorization is required.

Prior authorization number

Another name for prior authorization number is ________.

Certification number

What is an authorization number given to the referred physician called ?

Referral number

A (n) ________is a document a patient signs to guarantee when a referral authorization is pending .

Referral waiver

A (n) ________ensures that the patient will pay for services received if a referral is not documented in the time specified.

Referral waiver

Which health plan pays benefits first ?

Primary insurance

An additional policy that provides benefits is called _____.

Secondary insurance

Third insurance plan is called _________.

Tertiary insurance

A health plan that covers services not normally covered by a primary plan is called __________.

Supplementary insurance

_________explains how an insurance policy will pay if more than one policy applies.

Coordination of benefits

COB is the abbreviation for _________.

Coordination of benefits

___________guidelines that ensure that when a patient has more than one policy, maximum appropriate benefits are paid, but without duplication.

Coordination of benefits

Guideline that determines which parent has the primary insurance for a child is called _________.

Birthday rule

When determining a patient's primary insurance and the patient has two group policies, which one is the primary ?

The plan that has been in effect the longest period of time

When determining a patient's primary insurance and the patient has coverage under both a group and an individual plan, which one is the primary insurance ?

Group plan

When determining a patients' primary insurance and the patient is also covered as a dependent under another insurance policy, which is the primary insurance plan ?

The patient's plan

A coordination of benefits rule that is used to determine which plan is primary when a child has primary insurance under both parents plan is called __________.

Gender rule

__________is procedures that ensure billable services are recorded and reported for payment.

Charge capture

List of the diagnoses, procedures, and charges for a patient's visit is called a (n)________.

Encounter form

An encounter form is also called a (n) ________.

Superbill

Who completes the encounter form?

The provider

All communications with payer representatives should be __________.

Documented

After a medical assistant abstracts information about a patient's payer/plan, they contact the payer to verify three points. Which of the following is not one of these points?

The amount of the patient's premium

What is recorded on the encounter form ?

Diagnosis and procedures codes

PIF is the abbreviation for _________.

Patient information form

In the electronic transaction, HIPAA X12N 270/271 what does the 270 refer to ?

The inquiry that is sent

In the electronic transaction, HIPAA X12N 270/271 what does the 271 refer to ?

The answer retured by the payer

What should take place if an insured patient's policy does not cover a planned service ?

Patients should be informed that the payer does not pay for the service and that they are responsible for the charges

When health plan responds to an eligibility inquiry, it includes information. Which of the following is not a piece of information that would be included?

SOAP number

The Medicare program form that physicians must use to tell patients about uncovered services is called a (n) _________.

Advance beneficiary notice

When an insured patient's policy does not cover a planned service, who is obligated to arrange for payment before servicwes are given ?

The patient

When prior authorization is approved, where does the medical assistant enter the prior authorizatition number for use later on a health care claim ?

A. PMP

When a medical assistant at the specialist practice handles a referred patient, which of the following must the medical assistant do ?

C. Check that the patient has a referral number

The COB guidelines ensure that whena patient that has more than one policy, maximum appropriate benefits are paid, but without __________.

A. Duplication

A retired patient who has Medicare is covered by a spouse's employer's plan and the spouse is still employed. Which plan is primary ?

C. Spouse's plan

If a dependent child's primary insurance does not provide for the complete reimbursement of a bill, who is responsible to pay the balance?

D. The balance is submitted to the other parent's plan

When patients see a nonPAR, providers, they _______.

B. Pay more for these out-of-network visits

When the physician or medical assistant reviews information with the patient during the visit, where is this documented?

D. The medical record

In the PMP, a patient's visit for a new complaint is set up as a seperate _________.

B. Case

The pratice management program (PMP) contains__________.

A. Database of patients

Payers want the name of the patient on a claim__________.

D. To be exactly as it is shown on the insurance card

Only _______is required to give patients an acknowledgement of receipt of a privacy notice to read and sign.

B. A direct provider

If the planis an HMO that requires a primary care provider (PCP) , the general or family practice must verify which of the following?

B.The patient is assigned to the PCP as of the date of service

If a patient who is required to have a referral document does not bring one, the medical assistant then asks the patient to sign ________.

A. Referral waiver