Understanding Health Insurance: A Guide to Billing and Reimbursement (with Premium Website Printed Access Card and Cengage EncoderPro.com Demo Printed ... (Flexible Solutions - Your Key to Success) This book has a wealth of knowledge pertaining to Health Insurance and Billing. autonomous, centrally administered program of coordinated inpatient and outpatient palliative (relief of symptoms) services for terminally ill patients and their families. A type of liability insurance that covers physicians and other health care professionals for liability relating to claims arising from patient treatment. data analysis tool, which provides administrative hospital and state-specific data for specific CMS target areas. program for individuals with incomes below the federal poverty level. Next page. recipient eligibility verification system (REVS). Examine today's most important topics, such as managed care, legal and regulatory issues, coding systems and compliance, reimbursement methods, clinical … Medicare claim process that includes the following circumstances: a plan that is normally considered to be primary to Medicare issues a denial of payment that is under appeal; a patient who is physically or mentally impaired failed to file a claim to the primary payer; a worker's compensation claim has been denied and the case is slowly moving through the appeal process; or there is no response from a liability payer within 120 days of filing the claim, also called managed care plan; includes health maintenance organizations(HMOs), preferred provider organizations (PPOs), and provider- sponsored organizations (PSOs), through which a Medicare beneficiary may choose to receive health care coverage. special contract clause stipulating additional coverage above the standard contract. system by which payers deposit funds to the provider's account electronically. see outpatient pretreatment authorization plan (OPAP). Condition is "Good". agreement between Medicare beneficiary and physician or other practitioner who has "opted out" of Medicare for two years for all covered items and services furnished to Medicare beneficiaries; covers all Medicare Part A and Part B health care for individuals who can benefit the most from special care for chronic illnesses, care management of multiple diseases, and focused care management; such plans may limit membership to individuals who are eligible for both Medicare and Medicaid, have certain chronic or disabling conditions, and reside in certain institutions (e.g. offers choice and flexibility to subscribers who want to receive a full range of benefits along with the freedom to use any licensed health care provider. billed after primary insurance has paid contracted amount, the routing slip, charge slip, encounter form, or superbill from which the insurance claim was generated. requests and screens medical records for the Payment Error Prevention Program (PEPP) to survey samples for medical review, DRG validation, and medical necessity. amount for which the patient is financially responsible before an insurance policy provides coverage. any medical condition that was diagnosed and/or treated within a specified period of time immediately preceding the enrollee's effective date of coverage. legislation that allowed federally qualified HMOs to permit members to occasionally use non-HMO physicians and be partially reimbursed. provides global medical coverage for active employees and their dependents who spend more than six months outside the United States; any U.S. corporation with new or existing Blue coverage that sends members to work and reside outside the United States for 6 months or more is eligible for BlueWorld Expat, Federal Employee Health Benefits Program (FEHBP), also called the Federal Employee Program(FEP); an employer-sponsored health benefits program established by an act of Congress in 1959, which now provides benefits to more than 9 million federal enrollees and dependents through contracts with about 300 third-party payers. person responsible for paying health care fees. allows patients with this option to elect an alternative to the acute care setting. American Association of Medical Assistants (AAMA). It gives you complete control of your course, so you can provide engaging content, challenge every learner, and build student confidence. Solution Manual for Understanding Health Insurance: A Guide to Billing and Reimbursement – 2020, 15th Edition, Michelle Green, ISBN-10: 0357378644, ISBN-13: 9780357378649 claim Medicaid should not have originally paid, resulting in a deduction from the lump-sum payment made to the provider. program that allows BCBS subscribers to receive local Blue Plan health care benefits while traveling or living outside of their plan's area. Cengage Learning, Jan 1, 2018 - Business & Economics - 736 pages. nursing homes), combination of Medicare and Medicaid programs; available to Medicare-eligible persons with incomes below the federal poverty level. Inpatient Psychiatric Facility Prospective Payment System (IPF PPS). financial record source document used by providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. What is the purpose of workers' compensation? storage of documentation for an established period of time, usually mandated by federal and/or state law; its purpose is to ensure the availability of records for use by government agencies and other third parties. contributed to by an employer or employee pay-all plan; provides coverage to employees and dependents without regard to the enrollee's employment status (i.e., full-time, part-time, or retired). method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients prior to the administration of care. A coding system published by CMS that is used to report procedures, services, and supplies not classified in CPT. also called manual daily accounts receivable journal; chronological summary of all transactions posted to individual patient ledgers/accounts on a specific day. second physician is asked to evaluate the necessity of surgery and recommend the most economical, appropriate facility in which to perform the surgery (e.g., outpatient clinic or doctor's office versus inpatient hospitalization). Search. Examine today's most important topics, such as managed care, legal and regulatory issues, coding systems and compliance, reimbursement methods, clinical documentation improvement, coding for medical necessity, and common health insurance plans. Test Bank for Understanding Health Insurance: A Guide to Billing and Reimbursement – 2020, 15th Edition By Green. This comprehensive, inviting book presents the latest code sets and … Students cover the latest code sets, coding guidelines, and health plan claims completion instructions. associated with how an insurance plan is billed—the insurance plan responsible for paying health care insurance claims first is considered primary. representation of text as a single string of digits, which was created using a formula; for the purpose of electronic signatures, the message digest is encrypted (encoded) and appended (attached) to an electronic document. shows the status (by date) of outstanding claims from each payer, as well as payments due from patients. implemented as a result of the BBA of 1997; utilizes information from a patient assessment instrument to classify patients into distinct groups based on clinical characteristics and expected resource needs. used to document patient information released to authorized requestors; data is entered manually (e.g., three-ring binder) or using ROI tracking software. contract between employer and health care facility (or physician) where specified medical services were performed for a predetermined fee that was paid on either a monthly or yearly basis. Bundle: Understanding Health Insurance: A Guide to Billing and Reimbursement, 13th +Premium Web Site, 2 terms (12 months) Printed Access Card + … for MindTap Medical Insurance & Coding, 2 ter Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, legislation that mandates states to provide routine pediatric checkups to all children enrolled in Medicaid, Federal Medical Assistance Percentage (FMAP). $16.04 Next page. implemented (as a result of the BBA of 1997) to cover all costs (routine, ancillary, and capital) related to services furnished to Medicare Part A beneficiaries. American Health Information Management Association (AHIMA). Customers who bought this item also bought. determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan. This comprehensive, inviting book presents the latest code sets and guidelines. an HMO that meets federal eligibility requirements for a Medicare risk contract, but is not licensed as a federally qualified plan. Get FREE 7-day instant eTextbook access! Michelle Green. was considered landmark legislation because it launched truth-in-lending disclosures that required creditors to communicate the cost of borrowing, established the rights, liabilities, and responsibilities of participants in electronic funds transfer systems, Electronic Healthcare Network Accreditation Commission (EHNAC). income guidelines established annually by the federal government. What does the claims review process require? This comprehensive, easy-to-understand, updated book presents the latest code sets and guidelines. payment system that reimburses providers for services and procedures by classifying services according to relative value units (RVUs); also called Resource- Based Relative Value Scale (RBRVS) system. relative volume and types of diagnostic, therapeutic, and inpatient bed services used to manage an inpatient disease. An insurance agreement that protects business contents against fire, theft, and other risks. Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS). payment system for ambulance services provided to Medicare beneficiaries. decision-making tools used by providers to determine appropriate health care for specific clinical circumstances. 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. the region defined by code boundaries within a 40-mile radius of a military treatment facility. Textbook solutions for Understanding Health Insurance: A Guide to Billing and… 14th Edition GREEN and others in this series. Health Maintenance Organization (HMO) Assistance Act of 1973, authorized grants and loans to develop HMOs under private sponsorship; defined a federally qualified HMO as one that has applied for, and met, federal standards established in the HMO Act of 1973; required most employers with more than 25 employees to offer HMO, Healthcare Effectiveness Data and Information Set (HEDIS). National Committee for Quality Assurance (NCQA). mandates regulations that govern privacy, security, and electronic transactions standards for health care information. data entry software used to collect OASIS assessment data for transmission to state databases. Temporary Assistance for Needy Families (TANF). as mandated by the Patient Protection and Portable Care Act (PPACA), CMS established Medicare shared savings programs to facilitate coordination and cooperation among providers to improve quality of care for Medicare fee-for-service beneficiaries and to reduce unnecessary cost; accountable care organizations (ACOs) were created by eligible providers, hospitals and suppliers to coordinate care, and they are held accountable for the quality, cost and overall care of traditional fee-for-service Medicare beneficiaries assigned to the ACO. Prepare for a career in health information management and medical billing and insurance processing with Green's UNDERSTANDING HEALTH INSURANCE, 14E. provision in an insurance policy that requires the policyholder or patient to pay a specified dollar amount to a health care provider for each visit or medical service received.