Health Insurance Specialist Career Flashcards
AAPC
Professional association, previously known as the Americal 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)
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.
Centers for Medicare and Medicaid Services
formerly known as the Health Care financing Administration (HCFA): an administrative agency within the federal Department of Health and Human Services (DHHS).
claims examiner
employed by third-party payers to review health-related claims to determine whether the charges are reasonable and medically necessary based on the patient’s diagnosis.
coding
process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters (called codes) on the insurance claim.
Current Procedural Terminology
published by the American Medical Association; includes five-digit numeric codes and descriptions for procedures and services performed by providers (e.g. 99203 identifies a detailed office visit for a new patient).
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.
explanation of benefits (EOB)
report that details the results of processing a claim (e.g. payer reimburses provider $80 on a submitted charge of $100).
HCPCS 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.
health information technician
professionals who manage patient health information and medical records, administrator 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 determinations are made for HH PPS.
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 and independent contractor is not liable for the acts or omission of the independent contractor.”
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
coding system to be implemented on October 1st, 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)
coding system to be implemented on October 1st, 2015, and used to report procedures and services on inpatient claims.
internship
nonpaid professional practice experience that 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.
medical assistant
employed by a provider to perform administrative and clinical tasks that keep the office or clinic running smoothly.
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 code
commonly referred to as HCPCS level II codes; include five-digit alphanumeric codes from 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
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.
business liability insurance
protects business assets and covers the cost of lawsuits results from bodily injury, personal injury, and false advertising.
