HFMA Terms Questions with Correct Answers
provider - general
A party rendering medical care such as a physician or hopsital
facilities provider
Includes hospitals, skilled nursing facilities, assisted living facilities, home health agencies,
and ambulatory centers
professional provider
includes physicians, pharmacists, nurses, therapists, and allied health professionals
primary care
primary care physicians are usually trained in family practice, general practice, general
internal medicine, and pediatrics. Physicians serving in primary care roles usually treat
common medical conditions or injuries, and often provide preventive health screenings. They
are often viewed as serving as a coordinator of a patient's care, assessing a patient's condition,
and treating if a simple condition, or referring a patient to a specialist physician.
specialist
specialists normally do not provide primary care services, instead focusing their work based
on in-depth training in different diseases, body systems or types of health care service
third party payer
a health insurance plan paying for the services
out-of-pocket-payment
,payments by patients that can be required as a part of a health insurance plan are: deductible,
copayment, and coinsurance
deductible
the deductible is a pre-determined amount that the patient pays before the insurer begins to
pay for service
coinsurance
corinsurance is a percentage of the insurance payment amount that is paid by the patient,
along with the amount paid by the insurerer
indemnify
payment on behalf of the patient - costs covered under the insurance contract between the
patient and the insurer
claim
a bill for services provided
pre-authroization
permission by the insurer to render services to the patient before actually treating the patient.
This includes verification of payment for the service by the insurer
benefit payment
once the insurer has determined the claim is appropriate, a payment is made to the provider.
This payment is officially termed a benefit payment
beneficiary
insurers usually refer to the patient for which services are paid as the beneficiary
, a covered benefit
the services for which the insurer will pay are usually referred to as a covered benefit
denial
the insurer may determine that the claim from the provider is not a covered benefit and will
not pay the claim to the provider
remittance advice
the information an insurer provides on the payment decision
Medicare A
funded primarily by Medicare taxes paid by current workers to fund the costs of current
beneficiaries. Patients are usually eligible for Medicare Part _ if they are a US citizen over
age 65, disabled or have End Stage Renal Development and have paid Medicare wage taxes
for at least forty (40) calendar quarters - known as categorical eligibility. Medicare Part _
covers inpatient hospital services, certain organ transplants, ESRD treatment, inpatient skilled
nursing facility care, home health care and hospice care
Medicare B
Medicare Part _ is a voluntary program where a patient
that meets the age or medical condition requirements for
Medicare Part A (but not the requirement to pay taxes for
40 calendar quarters) may participate in this insurance
benefit. It is possible for a patient to be covered by
Medicare Part _ but not Medicare Part A.
Medicare Part D
provider - general
A party rendering medical care such as a physician or hopsital
facilities provider
Includes hospitals, skilled nursing facilities, assisted living facilities, home health agencies,
and ambulatory centers
professional provider
includes physicians, pharmacists, nurses, therapists, and allied health professionals
primary care
primary care physicians are usually trained in family practice, general practice, general
internal medicine, and pediatrics. Physicians serving in primary care roles usually treat
common medical conditions or injuries, and often provide preventive health screenings. They
are often viewed as serving as a coordinator of a patient's care, assessing a patient's condition,
and treating if a simple condition, or referring a patient to a specialist physician.
specialist
specialists normally do not provide primary care services, instead focusing their work based
on in-depth training in different diseases, body systems or types of health care service
third party payer
a health insurance plan paying for the services
out-of-pocket-payment
,payments by patients that can be required as a part of a health insurance plan are: deductible,
copayment, and coinsurance
deductible
the deductible is a pre-determined amount that the patient pays before the insurer begins to
pay for service
coinsurance
corinsurance is a percentage of the insurance payment amount that is paid by the patient,
along with the amount paid by the insurerer
indemnify
payment on behalf of the patient - costs covered under the insurance contract between the
patient and the insurer
claim
a bill for services provided
pre-authroization
permission by the insurer to render services to the patient before actually treating the patient.
This includes verification of payment for the service by the insurer
benefit payment
once the insurer has determined the claim is appropriate, a payment is made to the provider.
This payment is officially termed a benefit payment
beneficiary
insurers usually refer to the patient for which services are paid as the beneficiary
, a covered benefit
the services for which the insurer will pay are usually referred to as a covered benefit
denial
the insurer may determine that the claim from the provider is not a covered benefit and will
not pay the claim to the provider
remittance advice
the information an insurer provides on the payment decision
Medicare A
funded primarily by Medicare taxes paid by current workers to fund the costs of current
beneficiaries. Patients are usually eligible for Medicare Part _ if they are a US citizen over
age 65, disabled or have End Stage Renal Development and have paid Medicare wage taxes
for at least forty (40) calendar quarters - known as categorical eligibility. Medicare Part _
covers inpatient hospital services, certain organ transplants, ESRD treatment, inpatient skilled
nursing facility care, home health care and hospice care
Medicare B
Medicare Part _ is a voluntary program where a patient
that meets the age or medical condition requirements for
Medicare Part A (but not the requirement to pay taxes for
40 calendar quarters) may participate in this insurance
benefit. It is possible for a patient to be covered by
Medicare Part _ but not Medicare Part A.
Medicare Part D
