Understanding Health Insurance (a guide
to billing and reimbursement) Chapter One
Health Insurance Claim - ANS The documentation submitted to a third-party payer or
government program requesting reimbursement for health care services provided.
Preauthorization - ANS Prior approval for treatment.
What is a hold harmless clause? - ANS The patient is not responsible for paying what the
insurance plan denies in the contract between the provider and the insurance company and the
health care provider cannot collect the fees from the patient.
What is a no balance billing clause? - ANS A clause that protects patients from being billed for
amounts not reimbursed by payers except for copayments, coinsurance amounts, and
deductibles.
Nonparticipating provider - ANS A physician who does not participate in a particular health care
plan.
Health care provider - ANS A physician or other health care practitioner.
Centers for Medicare and Medicaid Services (CMS) - ANS The administrative agency within the
federal Department of Health and Human Services (DHHS).
What does the Secretary of the DHHS do? - ANS Announces the implementation of new
regulations about government programs such as Medicare or Medicaid.
What do health insurance specialists do? - ANS Review health-related claims to determine the
medical necessity for procedures or services performed before payment is made to the provider.
Another term for payment. - ANS Reimbursement.
Claims examiner - ANS Is employed by a third-party payer and reviews health-related claims to
determine whether the charges are reasonable and for medical necessity.
Medical necessity - ANS Involves linking every procedure or service code reported on the claim
to a condition code that justifies the need to perform that procedure or service.
, What does the claims review process require? - ANS Verification of the claim for completeness
and accuracy, as well as comparison with third-party payer guidelines to either authorize
appropriate payment or refer the claim to an investigator for a more thorough review.
Medical Assistant - ANS Is employed by a provider to perform administrative and clinical tasks
that keep the office or clinic running smoothly.
ICD-10-PCS codes are assigned to what hospital procedures? - ANS Inpatient
Coding - ANS The process of assigning ICD-10-cm, ICD-10-PCS CPT, and HCPCS level II
codes to diagnosis, procedures, and services.
Coding systems include... - ANS 1. International Classification of Diseases. 10th Revision,
Clinical Modification (ICD-10-CM)
2. International Classification of Diseases. 10th Revision. Procedural Coding System
(ICD-10-PCS)
3. Healthcare Common Procedure Coding System (HCPCS)
Healthcare Common Procedure Coding System (HCPCS) consists of? - ANS 1. Current
Procedural Terminology (CPT)
2. HCPCS level II codes (or national codes)
What is the International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM) coding system? - ANS A 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.
What is the International Classification of Diseases. 10th Revision Procedural Coding System
(ICD-10-PCS)? - ANS A coding system used to report procedures and services on inpatient
hospital claims.
What is Current Procedural Terminology (CPT)? - ANS A 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.
What is HCPCS level II codes (or national codes)? - ANS A coding system published by CMS
that is used to report procedures, services, and supplies not classified in CPT.
Ethics - ANS The principles of right or good conduct, and rules that govern the conduct of
members of a profession.
spondylosis vs spondylolysis - ANS Sponylosis is any condition of the spine.
Spondylolysis is a defect of the articulating portion of the vertebra.
to billing and reimbursement) Chapter One
Health Insurance Claim - ANS The documentation submitted to a third-party payer or
government program requesting reimbursement for health care services provided.
Preauthorization - ANS Prior approval for treatment.
What is a hold harmless clause? - ANS The patient is not responsible for paying what the
insurance plan denies in the contract between the provider and the insurance company and the
health care provider cannot collect the fees from the patient.
What is a no balance billing clause? - ANS A clause that protects patients from being billed for
amounts not reimbursed by payers except for copayments, coinsurance amounts, and
deductibles.
Nonparticipating provider - ANS A physician who does not participate in a particular health care
plan.
Health care provider - ANS A physician or other health care practitioner.
Centers for Medicare and Medicaid Services (CMS) - ANS The administrative agency within the
federal Department of Health and Human Services (DHHS).
What does the Secretary of the DHHS do? - ANS Announces the implementation of new
regulations about government programs such as Medicare or Medicaid.
What do health insurance specialists do? - ANS Review health-related claims to determine the
medical necessity for procedures or services performed before payment is made to the provider.
Another term for payment. - ANS Reimbursement.
Claims examiner - ANS Is employed by a third-party payer and reviews health-related claims to
determine whether the charges are reasonable and for medical necessity.
Medical necessity - ANS Involves linking every procedure or service code reported on the claim
to a condition code that justifies the need to perform that procedure or service.
, What does the claims review process require? - ANS Verification of the claim for completeness
and accuracy, as well as comparison with third-party payer guidelines to either authorize
appropriate payment or refer the claim to an investigator for a more thorough review.
Medical Assistant - ANS Is employed by a provider to perform administrative and clinical tasks
that keep the office or clinic running smoothly.
ICD-10-PCS codes are assigned to what hospital procedures? - ANS Inpatient
Coding - ANS The process of assigning ICD-10-cm, ICD-10-PCS CPT, and HCPCS level II
codes to diagnosis, procedures, and services.
Coding systems include... - ANS 1. International Classification of Diseases. 10th Revision,
Clinical Modification (ICD-10-CM)
2. International Classification of Diseases. 10th Revision. Procedural Coding System
(ICD-10-PCS)
3. Healthcare Common Procedure Coding System (HCPCS)
Healthcare Common Procedure Coding System (HCPCS) consists of? - ANS 1. Current
Procedural Terminology (CPT)
2. HCPCS level II codes (or national codes)
What is the International Classification of Diseases, 10th Revision, Clinical Modification
(ICD-10-CM) coding system? - ANS A 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.
What is the International Classification of Diseases. 10th Revision Procedural Coding System
(ICD-10-PCS)? - ANS A coding system used to report procedures and services on inpatient
hospital claims.
What is Current Procedural Terminology (CPT)? - ANS A 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.
What is HCPCS level II codes (or national codes)? - ANS A coding system published by CMS
that is used to report procedures, services, and supplies not classified in CPT.
Ethics - ANS The principles of right or good conduct, and rules that govern the conduct of
members of a profession.
spondylosis vs spondylolysis - ANS Sponylosis is any condition of the spine.
Spondylolysis is a defect of the articulating portion of the vertebra.
