My #5

1. The process of obtaining the dollar amount approved for a medical procedure or service before the procedure or service is scheduled.

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2. Obtained from health insurance companies and gives the provider approval to render the medical service.

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3. The electronic transfer of data (e.g., electronic claims) between two or more entities.

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4. A process done prior to claims submission to examine claims for accuracy and completeness.

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5. A contract between a provider and an insurance company in which the health plan pays a monthly fee per patient while the provider accepts the patient’s copay as payment in full for office visits.

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6. The process of obtaining the dollar amount approved for a medical procedure or service before it is scheduled.

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7. Form used by most health insurance payers for claims submitted by providers and suppliers.

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8. Process by which an insurance carrier allows a provider to submit insurance claims directly to the carrier electronically.

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9. A healthcare provider who has signed a contract with a health insurance plan to accept lower reimbursements for services in return for patient referrals.

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a. Precertification

b. CMS-1500

c. Direct Billing

d. Release of information

e. Participating provider

f. Electronic data interchange

g. Capitation agreements

h. Audit

10. An intermediary that accepts the electronic claim from the provider, reformats the claim to the specifications outlined by the insurance plans, and submits claim.

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11. An identifier assigned by the Centers for Medicare and Medicaid Services (CMS) that classifies the healthcare provider by license and medical specialties.

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12. On the EOB where the payer indicates the conditions under which the claim was paid or denied.

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13. Found on the patient’s health insurance ID card and is needed to identify the specific health plan to which the claim should be submitted.

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14. When provider may be inclined to code to a higher specificity level than the service provided actually involved.

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15. Claims with incorrect, missing, or insufficient data.

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16. A form that is sent by the insurance company to the provider who submitted the insurance claim which an accompanying check or a document indicating that funds were electronically transferred.

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17. Insurance carrier’s decision if the tests and treatments indicated by the CPT and HCPCS codes meet the accepted standard of practice to treat the patient’s diagnosis indicated by the ICD code.

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18. A patient financial responsibility that the subscriber for the policy is contracted per year to pay toward his or her healthcare before the insurance policy reimburses the provider.

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19. When a lower specificity level, or more generalized code is assigned.

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20. A policy provision in which the policyholder and the insurance company share the cost of covered medical services in a specified ratio.

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21. A patient financial responsibility that is due at the time of the office visit.

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22. Determining whether fraudulent medical billing practices were done with purpose or by accident.

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a. Transmitter ID

b. Claims clearinghouse

c. Downcoding

d. Explanation of benefits (EOB)

e. National Provider Identifiers (NPIs)

f. Remark codes

g. Medical necessity

h. Dirty claims

i. Copayment

j. Coinsurance

k. Intentional

l. Upcoding

m. Deductible