Ch. 01 Health Insurance Specialist Career

Question 1

AAPC

Answer 1

American Academy of Professional Coders, professional association

Question 2

AAMA

Answer 2

American Association of Medical Assistants, professional association

Question 3

AHIMA

Answer 3

American Health Information Management Association,
Founded in 1928 to improve the quality of medical records and currently advances the HIM profession

Question 4

bonding insurance

Answer 4

Insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee.

Question 5

business liability insurance

Answer 5

Protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury and false advertising.

Question 6

CMS

Answer 6

Centers for Medicare and Medicaid Services, formerly known as the Health Care Financing Administration (HCFA), an administrative agency within the DHHS.

Question 7

claims examiner

Answer 7

employed by third-party payers to review health-related claims to determine whether charges are reasonable and medically necessary based on the diagnosis.

Question 8

coding

Answer 8

process of reporting diagnoses, procedures and services as numeric and alphanumeric characters (codes) on the insurance claim.

Question 9

CPT

Answer 9

Current Procedural Terminology,
published by the AMA includes 5 digit codes and descriptors for procedures and services performed by providers.

Question 10

embezzle

Answer 10

illegal transfer of money or property as a fraudulent action; to steal money from an employer.

Question 11

E & O

Answer 11

errors and omissions insurance,
professional liability insurance.

Question 12

ethics

Answer 12

principle of right or good conduct; rules that govern the conduct of members of a profession.

Question 13

EOB

Answer 13

explanation of benefits, a report that details the results of processing a claim.

Question 14

HCPCS Level II Codes

Answer 14

national codes published by CMS,
5 digit alphanumeric codes for procedures, services, and supplies not classified in CPT.

Question 15

health care provider

Answer 15

physician or other health care practitioner.

Question 16

health information technician

Answer 16

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.

Question 17

health insurance claim

Answer 17

documentation submitted to insurance plan to request reimbursement for health care services provided.

Question 18

health insurance specialist

Answer 18

person who reviews health insurance claims to match medical necessity to procedures or services performed before reimbursement is made to provider.

Question 19

HCPCS

Answer 19

Healthcare Common Procedure Coding System, coding system that consists of CPT, national codes (level II), and local codes (level III) (discontinued in 2003).

Question 20

hold harmless clause

Answer 20

policy that the patient is not responsible for paying what the insurance plan denies.

Question 21

independent contractor

Answer 21

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.

Question 22

ICD-10-CM

Answer 22

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.

Question 23

ICD-10-PCS

Answer 23

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.

Question 24

internship

Answer 24

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.

Question 25

medical assistant

Answer 25

employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly.

Question 26

medical malpractice insurance

Answer 26

type of liability insurance, covers physicians and other health care professionals for liability claims arising from patient treatment.

Question 27

medical necessity

Answer 27

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.

Question 28

national codes

Answer 28

HCPCS Level II codes, include 5 digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT.

Question 29

professional liability insurance

Answer 29

provides protection from liability as a result of errors and omissions then performing their professional services, also called errors and omissions insurance.

Question 30

professionalism

Answer 30

conduct or qualities that characterize a professional person.

Question 31

property insurance

Answer 31

protects business contents against fire, theft and other risks.

Question 32

reimbursement specialist

Answer 32

see health insurance specialist.

Question 33

remittance advice (remit)

Answer 33

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.

Question 34

respondeat superior

Answer 34

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.

Question 35

scope of practice

Answer 35

health care services, determined by the state, that an NP and PA can perform.

Question 36

workers’ compensation insurance

Answer 36

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.