Lesson 1 Flashcards
Health Insurance 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.
Health care provider
A physician or other health care practitioner
Centers of Medicare and Medicaid services (cms)
Administrative agency within the federal department of health and human services (DHHS)
Coding
The process of assigning ICD-10, icd-10-pcs, cpt, hcpcs level ll codes which contain alphanumeric and numeric characters.
To diagnoses, procedures and services.
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 physicians office.
Icd-10-pcs
Coding system used to report procedures and services on inpatient hospital claims.
Hcpcs
Two levels.
Cpt- coding system published by the American medical association that is used to report procedure and services performed during outpatient and physician office encounters and professional services provided to inpatients.
Hcpcs level ll codes (national codes)- coding system published by CMS that is used to report procedures , services and supplies not classified in cpt
Medical necessity
Involved linking every procedure or service code reported in the claim to a condition code that justifies the need to perform that procedure or service.
Health insurance specialist (reimbursement specialist)
Review health related claims to match medical necessity to procedures or services performed before payment is made to the provider.
Claims examiner
Employed by a third part layer reviews health related claims to determine whether the charges are reasonable and for medical necessity.
Medical assistant
Is employed by a provider to perform administrative and clinical tests that keep the office or clinic running smooth.
Health Information technicians
Manage patient health Info and medical records, administer computer Information systems, and code diagnoses and procedures for health care services provided to patients.
EOB
Explanation of benefits
Which is a report detailing the results of processing a claim.
Remittance advice (or remit)
A notice sent by the Insurance company that contains payment Information about a claim.
Respondeat superior
Latin for let the master answer. The employer is liable for the actions and omissions of employees
Diagnosis codes
Are alphanumeric codes that identify diseases, disorders, symptoms , Injuries and other reasons for patient encounters.
Procedure codes
Are numeric codes that identify commonly accepted description of medical procedures, services and supplies.
Health insurance claim
A physicians request for payment from an insurance company for covered services, procedures and supplies provided to the patient.
A claim also contains the patients diagnoses to justify the need for the services, procedures and supplies.
Payer
A payer is the insurance company that provided healthcare coverage. Sometimes referred to as the “third party payer”
Ambulatory
An ambulatory healthcare setting is where services are provided on an outpatient basis, without admission to a hospital or other facility.
A doctors office is an example.
Healthcare provider
Means a person licensed, certified or otherwise authorized or permitted by law to administer healthcare and establish the patients diagnosis and treatment plan.
Professional liability insurance
Also known as errors and omissions insurance. Which provides protection from liability from errors in performing services.
AAPC
Founded to elevate standards of medical coding. Provided certification , education and recognition.
AAMA
American association of medical assistants
AHIMA
American health Information management association
Founded in 1928 to improve quality of medical records and advanced health information management
AMBA
American medical billing association