Chapt 1 Flashcards
health insurance claim
claim is the documentation submitted to a third-party payer or government program requesting reimbursement for health care services provided
hold harmless clause
(patient is not responsible for paying what the insurance plan denies) in the contract, the health care provider cannot collect the fees from the patient.
health care provider
is a physician or other health care practitioner (e.g., nurse practitioner, physician’s assistant).
Centers for Medicare and Medicaid Services (CMS)
which is the administrative agency within the federal Department of Health and Human Services (DHHS)
Coding
is the process of assigning ICD-10-CM, ICD-10-PCS, CPT, and HCPCS level II codes, which contain alphanumeric and numeric characters (e.g., A01.1, 0DTJ0ZZ, 99201, K0003), to diagnoses, procedures, and services.
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
coding system used to report diseases, injuries, and other reasons for inpatient and outpatient encounters, such as an annual physical examination performed at a physician’s office
International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)
coding system used to report procedures and services on inpatient hospital claims coding system used to report procedures and services on inpatient hospital claims
Current Procedural Terminology (CPT)
coding system published by the American Medical Association that is used to report procedures and services performed during outpatient and physician office encounters, and professional services provided to inpatients
HCPCS level II codes (or national codes)
coding system published by CMS that is used to report procedures, services, and supplies not classified in CPT
Medical necessity
involves linking every procedure or service code reported on the claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service
Health insurance specialists (or reimbursement specialists)
review health-related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider.
claims examiner
employed by a third-party payer reviews health-related claims to determine whether the charges are reasonable and for medical necessity.
Medical necessity
involves linking every procedure or service code reported on the claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service
Claims review process requires verification of the claim
- Authorize appropriate payment
2. Refer the claim to an investigator for a more thorough review
medical assistant
is employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly
internship
internship benefits students and facilities that accept students for placement. Students receive on-the-job experience prior to graduation, and the internship assists them in obtaining permanent employment.
AAPC -
professional association, previously known as the American Academy of Professional Coders, established to provide a national certification and credentialing process, to support the national and local membership by providing educational products and opportunities to networks, and to increase and promote national recognition and awareness of professional coding.
American Association of Medical Assistants (AAMA)
enables medical assisting professionals to enhance and demonstrate the knowledge, skills, and professionalism required by employers and patients; as well as protect medical assistants’ right to practice.
American Health Information Management Association (AHIMA)
American Health Information Management Association (AHIMA) - founded in 1928 to improve the quality of medical records, and currently advances the health information management (HIM) profession toward an electronic and global environment, including implementation of ICD-10-CM and ICD-10-PCS in 2013.
bonding insurance
- an insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee. It protects the financial operations of the employer.
business liability insurance -
an insurance agreement that guarantees repayment for financial losses resulting from the act or failure to act of an employee. It protects the financial operations of the employer.
business liability insurance
- protects business assets and covers the cost of lawsuits resulting from bodily injury, personal injury, and false advertising.
Embezzle
the illegal transfer of money or property as a fraudulent action; to steal money from an employer.
errors and omissions insurance
see professional liability insurance.
Ethics
principle of right or good conduct; rules that govern the conduct of members of a profession.
nation of benefits (eob)
report that details the results of processing a claim (e.g., payer reimburses provider $80 on a submitted charge of $100).
CPCS level ii codes
- national codes published by CMS, which include five-digit alphanumeric codes for procedures, services, and supplies not classified in CPT.
health care provider
physician or other health care practitioner (e.g., physician’s assistant).
health information technician
- professionals who manage patient health information and medical records, administer computer information systems, and code diagnoses and procedures for health care services provided to patients
health insurance claim
documentation submitted to an insurance plan requesting reimbursement for health care services provided (e.g., CMS-1500 and UB-04 claims).
health insurance specialist
person who reviews health-related claims to match medical necessity to procedures or services performed before payment (reimbursement) is made to the provider; see also reimbursement specialist
Healthcare Common Procedure Coding System (HCPCS
coding system that consists of CPT, national codes (level II), and local codes (level III); local codes were discontinued in 2003; previously known as HCFA Common Procedure Coding System.
hold harmless clause
policy that the patient is not responsible for paying what the insurance plan denies.
independent contractor-
- defined by the ‘Lectric Law Library’s Lexicon as “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.”
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM
coding system to be implemented on October 1, 2015, and used to report diseases, injuries, and other reasons for inpatient and outpatient encounters.
International Classification of Diseases, 10th Revision, Procedural Coding System (ICD-10-PCS)
international classification -
coding system to be implemented on October 1, 2015 and used to report procedures and services on inpatient claims.
medical malpractice insurance
- a type of liability insurance that covers physicians and other health care professionals for liability claims arising from patient treatment.
medical necessity
- involves linking every procedure or service code reported on an insurance claim to a condition code (e.g., disease, injury, sign, symptom, other reason for encounter) that justifies the need to perform that procedure or service.
national codes
commonly referred to as HCPCS level II codes; include five-digit alphanumeric codes for procedures, services, and supplies that are not classified in CPT (e.g., J-codes are used to assign drugs administered).
professional liability insurance
- provides protection from liability as a result of errors and omissions when performing their professional services; also called errors and omissions insurance.
Professionalism
conduct or qualities that characterize a professional person.
property insurance
protects business contents (e.g., buildings and equipment) 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 (from date/thru date), 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 -
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.
