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ch. 3 and 4 medical insurance

Which statement is correct regarding the insurance industry
The insurance industry is among the world’s largest businesses
most legal issues of private health insurance claims fall under
civil law
when does the physician/patient contract begin
when the physician accepts the patient and agrees to treat the patient
most physician/patient contracts are
implied
When a patient carries private medical insurance, the contract for treatment exists between the
physician and the patient
an emancipated minor is a person
younger than the age of 18 who lives independently
the contract in a workers compensation case exists between the
physician and the insurance company
in health insurance, the insured is also known as the
subscriber, member, policy holder
the insured is always the
individual enrollee or organization protected
A policy in which the insurer cannot increase premium rates and must renew the policy until the insured reaches the age specified in the contract is a _______ policy.
noncancelable
the reason for a coordination of benefits statement in a health insurance policy is to
prevent duplication or overlapping of payments for the same medical expense.
Mr. Talili has two medical insurance policies. to prevent duplication of payment for the same medical expense, the policies include a ______ statement.
coordination of benefits
in cases of divorce, the decision as to which parent should be responsible for payment of the child’s services should be made by the
court system
if a child has health insurance coverage from two parents, according to the birthday law
the health plan of the person whose birthday (month and day) falls earlier in the calendar year will pay first
according to the birthday law if both the mother and the father have the same birthday, the
plan of the person who has coverage longer is the primary payer
conditions that existed and were treated before the health insurance policy was issued are called
preexisting
an attachment to an insurance policy that excludes certain illnesses or disabilities that would otherwise be covered is referred to as a
waiver
what is the correct term used to determine if a procedure is covered and medically necessary
preauthorization
mrs. thompsett leaves her place of employment. she is eligible to transfer her medical insurance coverage from a group to an individual contract this is known as _____ privilege
conversion
why would conversion from a group policy to an individual policy be advantageous
benefits would be increased
mr. Ott was laid off from his job. he is protected by consolidated omnibus budget reconciliation act (COBRA), which requires his employer to
extend group health insurance coverage for 18 months
What is the minimum number of employees a company must have to meet the criteria of the COBRA for continued medical benefits if an employee is laid off from a company
20
the act created to protect workers and their families so that they can get and maintain health insurance if they change or lose their jobs is called the
HIPAA
an organization of physicians, sponsored by a state or local medical association, concerned with the development and delivery of medical services and the cost of health care is known as a
foundation for medical care
a type of managed care organization created by the 1982 tax equity and fiscal responsibility act (TEFRA) that allows for enrollment of medicare beneficiaries into managed care plans is to a
competitive medical plan (CMP)
a state and federal program for children who are younger than 21 years of age and have special health care needs is
maternal and child health programs (MCHP)
A patient intake sheet is also called a
patient registration form
The first document obtained in the initial patient visit is a
patient information form
assignment of benefits is
the transfer of ones legal right to collect an amount payable under an insurance contract
an encounter form may also be known as a
patient service slip
the source document for insurance claim data is the
superbill
a daily record sheet used to record daily business transactions is called a
day sheet
under HIPAA guidelines, physicians must send all claims electronically if they have _____ full-time employees
more than 10
an insurance claims register facilitates
follow-up of insurance claims
when the physicians services have been submitted to the patients insurance company by the physicians office, the patient should
be sent a monthly statement indicating the insurance company has been billed
independent practice association (IPA)
a medical capitation plan in which treatment is delivered via a clinic or independent physician that provides a number of basic medical services for a fixed capitation payment per month
medicaid
a program sponsored jointly by federal and state governments for medically indigent persons, aged individuals who meet certain financial requirements, and the disabled
state disability or unemployment compensation disability (UCD)
insurance that covers off the job injury or sickness and is paid by deductions from a persons paycheck
tricare
government sponsored program that provides hospital and medical services for dependents of active duty uniform service members, military retirees and their families, and survivors of uniformed services
workers compensation insurance
a contract that insures a person against on the job injury or illness
CHAMPVA
provides coverage for spouses and children of veterans with total, permanent, service connected disabilities or for the surviving spouses and children of veterans who died as a result of service connected disabilities
health maintenance organization (HMO)
an organization that provides a wide range of comprehensive health care services for a specified group at a fixed periodic payment
disability income insurance
a form of health insurance that provides periodic payments to replace income when the insured is unable to work as a result of illness, injury, or disease
medicare
the hospital insurance system and supplementary medical insurance for those older than 65 years of age, created by the 1965 Amendments to the social security act
treating or performing physician
renders a service to a patient
ordering physician
directs selection, preparation, and administration of tests, medication, or treatment
attending physician
legally responsible for the care and treatment given to a patient
consulting physician
gives an opinion regarding a specific problem that is requested by another doctor
referring physician
sends the patient for tests or treatment or to another physician for consultation
primary care physician
oversees care of patients in managed care plans and refers patients to see specialists when needed
teaching physician
responsible for training and supervising medical students
non physician practitioner
clinical nurse specialist or licensed social worker who treats a patient for a specific medical problem and uses the results of a diagnostic test in managing a patients medical problem
resident physician
performs one or more ears of training in a specialty area while working at a hospital (medical center)
RLQ
right lower quadrant
DC
discharge
WNL
within normal limits
R/O
rule out
URI
upper respiratory infection
C (line on top)
with

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