CHAM QUESTION WITH 100 % CORRECT ANSWERS | VERIFIED

Health ins plan in which pts may select dr or hosp and providers bill the pt or their ins their normal fees for svc. coverage is usually provided for diag test or cond caused by disease, illness, or injury. Routine screening and well vts are not always covered, also known as "fee-for-service". - AnswerIndemnity Which organization evaluates the policies, procedures, and outcomes of care provided by hospitals? This organization has been responsible for accrediting healthcare organizations since the middle 1950s and determines whether the organization is continually monitoring and improving the quality of care they provide. - Answer-Joint Commission term used when a patient is admitted to the hospital w/ the expectation that the pt will stay for a period of 24 hrs or more - Answer-Inpatient Unique number associated with your name in the medical record MRN - Answer-Medical Record Number provider contract clause which states the provider agrees to accept the amount the plan pays as payment in full not to bill the members/(except co-pays, coinsurand deductables) - Answer-No Balance Billing Provision federal legislation that attempts to eliminate unbundling or other inappropriate reporting of procedural codes for professional medical services rendered to patients CCI, Federal legislation that attempts to eliminate unbundling or other inappropriate reporting of procedural codes for professional medical services rendered to patients - Answer-Correct Coding Initiative To pay for medical services and items that Medicare does not cover and Medicare's coinsurance and deductibles, beneficiaries may purchase a supplemental insurance. Private insurance designed to help pay for those amounts that are typically the patient;s responsibility under Medicare. - AnswerMedigap Insurance RN usually with a bacholer's degree who has successfully completed additional training in a NP program at the masters or doctoral level - Answer-Nurse Practicionercertificate issued by a military treatment facility that cannot provide needed care to TRICARE Standard beneficiaries. This means the beneficiary can seek care from a civilian provider and reimbursement will be approved. NAS certificates are not required for emergency care. - AnswerNon-Availability Statement Tries to balance the need for cost containment with access and quality of service. - Answer-Managed Care Is permanent,aka Enterprise MPI or EMPI - Answer-Master Patient Index Medicare Secondary Payer It is important for the insurance billing specialist to determine whether a patient's Medicare coverage is primary or secondary - Answer-MSP protects the insured party from being held liable for other's financial losses covers the insured if injuries or damages are caused to other people or their property. - AnswerLiability Insurance Office of Inspector General The federal agency that investigates cases of Medicare or Medicaid fraud. - Answer-OIG One who does not fall w/in the norm; a term typically used in utilization review. A provider who uses either too many or too few services. - Answer-Outlier Medical services, procedures, or supplies that are reasonable and necessary for the diagnosis or treatment of a patient's medical condition, in accordance with the standards of good medical practice, performed at the proper level, and provided in the most appropriate setting. - AnswerMedically Necessary requires that manufacturers provide the lowest prices to any customer or Medicaid patient by rebating each state Medicaid agency the difference between its average price and the lowest price. It requires that an "offer to counsel" is made to every patient and drug utilization review is performed for every patient failure to do this may result in the loss of Medicaid funds. authorizes government sponsored demonstration projects relating to the provision of pharmaceutical care. patient profiles are to be maintained for all patients. OBRA - Answer-Omnibus Budget Reconciliation ActInsurance that usually will not require referrals to a specialist, but certain services such as nutrition service considered ancillary services do need to be authorized. Typically as a copayment. - AnswerOpen Access And notice issued within two days of admission and again within two days of discharge that explains the inpatients what to do if they feel they are being discharged to soon - Answer-Important Message from Medicare Indemnity (IM) A number issued by SSA to individuals or beneficiaries who are entitled to Medicare benefits. - Answer-Health Insurance Claim Number Health maintenance organization. A prepaid health insurance plan in which patients receive health care from designated providers - Answer-HMO