Term
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Definition
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Term
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Definition
| Not a plan with managed care |
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Term
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Definition
| Maximum amount paid by insurance company |
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Term
| Employee retirement services administrators (ESRA) Administrative Service Org (ASO) |
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Definition
| Hired by self insurance groups to manage and pay claims |
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Definition
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Term
| EOB- Explaination of Benefits |
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Definition
| statement created by carrier showing how a claim is adjudicated |
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Definition
| people enrolled in the managed care plan |
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Term
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Definition
group of providers working under one umbrella to get discounted services
Preferred Provider Org |
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Term
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Definition
| trained in a medical specialty |
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Term
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Definition
| multi-specialty practice where services are provided in a complex owned by HMO |
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Term
| IAP Individual Practice Association |
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Definition
| contracts with HMO's where services are provided by providers who supply all Pt. care |
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Term
| NCQA National Commitee Quality Assurance |
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Definition
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Term
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Definition
| written complaint submitted by the person covered by the plan |
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Term
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Definition
| pre-printed form listing procedure and diagnoses common to the practice as well as codes and fees |
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Term
| patient/insured section of CMS-1500 |
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Definition
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Term
| common cause for insurance claims to be rejected |
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Definition
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Term
| advantage to electronically filing claims |
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Definition
| reduces reimbursement time |
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Term
| primary objective in submitting claims |
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Definition
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Term
| when is it necessary to use a claim attachment |
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Definition
| supporting documentation i.e unlisted procedure code (ending in 99) |
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Term
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Definition
| review for "necessity and appropriateness" |
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Term
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Definition
| to be seen and treated by specialist |
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Term
| FFS Fee for Service (Indemnity) |
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Definition
traditional or indemnity
out of pocket 1) premium 2)co-insurance 3)deductible |
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Term
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Definition
| PAR-providers have 1 year from the last date they saw the Pt. |
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Term
| PCP Primary Care Physician |
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Definition
| oversees the entire care of PT. |
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Term
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Definition
| sm fee Pt. pays up front to see physician |
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Term
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Definition
| when the Pt. sees another provider for expert opinion |
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Term
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Definition
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Term
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Definition
| responsible for revising the CMS-1500 |
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Term
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Definition
| must be printed in OCR scannable red ink and has 33 blocks and all CAPS |
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Term
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Definition
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Term
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Definition
| most common format used for text files |
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Term
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Definition
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Term
| guidelines for OCR scannable claims |
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Definition
| red ink -all CAPS- 8 digit birthday- no punctuation |
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Term
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Definition
| medicare claims must be submitted electronically unless a waiver is granted |
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Term
| documents needed to complete a paper CMS-150 |
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Definition
| Pt. info/Insurance card/health record |
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Term
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Definition
| Pt. charges and payment record |
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Term
| How do you correctly write a birthday on CSM-1500 |
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Definition
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Term
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Definition
| submitting insurance claims to directly to a 3rd party payer |
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Term
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Definition
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Term
| why were CMS-1500 revised |
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Definition
| HIPAA mandated NPI's (National Provider Identification) |
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Term
| EIN (Employer Identification Number) |
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Definition
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Term
| bottom half of the CSM-1500 |
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Definition
| physician/supplier information |
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Term
| 2 main sections of the CSM-1500 |
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Definition
| Pt. and provider information |
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Term
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Definition
| important responsibility of the health insurance professional |
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Term
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Definition
| Name of insurance, policy number, co-pay information etc. |
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Term
| what should the medical record document? |
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Definition
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