Ch. 01 Health Insurance Specialist Career Flashcards
AAPC
American Academy of Professional Coders, professional association
AAMA
American Association of Medical Assistants, professional association
AHIMA
American Health Information Management Association,
Founded in 1928 to improve the quality of medical records and currently advances the HIM profession
bonding insurance
Insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee.
business liability insurance
Protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury and false advertising.
CMS
Centers for Medicare and Medicaid Services, formerly known as the Health Care Financing Administration (HCFA), an administrative agency within the DHHS.
claims examiner
employed by third-party payers to review health-related claims to determine whether charges are reasonable and medically necessary based on the diagnosis.
coding
process of reporting diagnoses, procedures and services as numeric and alphanumeric characters (codes) on the insurance claim.
CPT
Current Procedural Terminology,
published by the AMA includes 5 digit codes and descriptors for procedures and services performed by providers.
embezzle
illegal transfer of money or property as a fraudulent action; to steal money from an employer.
E & O
errors and omissions insurance,
professional liability insurance.
ethics
principle of right or good conduct; rules that govern the conduct of members of a profession.
EOB
explanation of benefits, a report that details the results of processing a claim.
HCPCS Level II Codes
national codes published by CMS,
5 digit alphanumeric codes for procedures, services, and supplies not classified in CPT.
health care provider
physician or other health care practitioner.
health information technician
professional who manage patient health information and medical records, administer computer information systems, and code diagnosis and procedures for health care services provided to patients.
health insurance claim
documentation submitted to insurance plan to request reimbursement for health care services provided.
health insurance specialist
person who reviews health insurance claims to match medical necessity to procedures or services performed before reimbursement is made to provider.
HCPCS
Healthcare Common Procedure Coding System, coding system that consists of CPT, national codes (level II), and local codes (level III) (discontinued in 2003).
hold harmless clause
policy that the patient is not responsible for paying what the insurance plan denies.
independent contractor
A person who performs services for another under an express or implied agreement and who is not subject to the other’s control, or right to control, of the manner and means of performing the services. The organization that hires an independent contractor is not liable for the acts or omissions of the independent contractor.
ICD-10-CM
International Classification of Diseases, 10th Revision, Clinical Modification,
coding system implemented on 10/1/2015, used to report diseases, injuries, and other reasons for inpatient and outpatient encounters.
ICD-10-PCS
International Classification of Diseases, 10th Revision, Procedural Coding System, coding system implemented on 10/1/2015, used to report procedures and services on inpatient claims.
internship
non-paid professional practice experience that benefits students and facilities that accept students for placement; students receive on-the-job experience prior to graduation and internship assists them in obtaining permanent employment.
medical assistant
employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly.
medical malpractice insurance
type of liability insurance, covers physicians and other health care professionals for liability claims arising from patient treatment.
medical necessity
linking every procedure or service code reported on an insurance claim to a condition code that justifies the need to perform that procedure or service.
national codes
HCPCS Level II codes, include 5 digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT.
professional liability insurance
provides protection from liability as a result of errors and omissions then performing their professional services, also called errors and omissions insurance.
professionalism
conduct or qualities that characterize a professional person.
property insurance
protects business contents against fire, theft and other risks.
reimbursement specialist
see health insurance specialist.
remittance advice (remit)
electronic or paper-based report of payment sent by the payer to the provider; includes patient name, patient health insurance claim (HIC) number, facility provider number/name, dates of service, type of bill (TOB), charges, payment information, and reason and/or remark codes.
respondeat superior
Latin for “let the master answer”, legal doctrine holding that the employer is liable for the actions and omissions of employees performed and committed within the scope of their employment.
scope of practice
health care services, determined by the state, that an NP and PA can perform.
workers’ compensation insurance
insurance program, mandated by federal and state governments, that requires employers to cover medical expenses and loss of wages for workers who are injured on the job or who have developed job-related disorders.
