CCMA Exam Domain 5

Medicare

provides insurance to patients who are over 65 years old or to younger patients with disabilities or End Stage Renal Disease (ESRD).

• part A is to cover IP care in hospitals and nursing facilities

• Part B is OP care, and certain preventive services

• Part C is part A and part b coverage, provided by private companies

• Part D is Rx drug coverage in OP settings

Medicaid

plans jointly managed by federal and state governments that provide health benefits for indigent or low income patients. Federal government defines the standards but its mostly administered at state level.

TRICARE

provides benefits to military personnel, retired personnel, veterans and families of the such. CHAMPVA benefits the families of veterans

Health maintenance organization (HMO)

mostly covers in network providers, but may accept out of network

Exclusive provider organization (EPO)

this type of plan generally only works with in network providers with exception of an emergency

Point of service (POS)

type of plan that encourages using in network providers by providing discounted prices. Referrals are required for specialists

Preferred provider organization (PPO)

Can use in network providers at discounted prices. Patients can use out of network without referrals

Paper claim

CMS 1500 claim form, for Medicare patients

Usual, customary, and reasonable fee (UCR)

compares the fee used by the doctor with the fee charged by most doctors in a community and the appropriate price for a service

Acceptance of assignment

agreement by the provider of the amount established by the insurer

Allowed charge

maximum charge that will covered by the insurer

Disallowed charge

difference between amount billed by the provider and amount paid by insurer (resulting amount is written out)

Limiting charge

for providers that do not accept assignments, this is the highest charge

Waiting period

the time during which the insured person is not eligible to receive the benefits from the plan

EOB

statement sent by a health insurance company to a patient (and/or healthcare provider) after a healthcare service has been processed

Utilization

usage pattern for the service

Health information management

the hospital dept that manages the medical records

Patient encounter form

document with details from a visit, used for billing

Advanced beneficiary notice (ABN)

notice issued by healthcare providers to Medicare beneficiaries when a medical service is not covered by Medicare.

Current Procedural Terminology (CPT)

a listing of standardized alphanumeric codes medical coders use to report services. Uniform process for reporting medical services

Prior Authorization (PA)

request that is necessary before a healthcare provider can provide a medical service, such as surgery, lab test, imaging study, rx, or other service. PA is required when insurance plan does not cover a medical item or service

International Classification of Diseases (ICD)

a standardized system for coding diagnoses, symptoms, and procedures maintained by the WHO

used during billing process to standardize and simplify

US uses ICD-10-CM for diagnostic codes and ICD-10-PCS for procedure codes in IP settings.

Healthcare Financing Administration Common Procedure Coding System (HCPHS)

standardized coding system used by Medicare and other healthcare providers to report medical procedures, services, and supplies

Mobile healthcare apps

Teladoc, MDlive, and Amwell provide medical consultation to pts. Lecturio and Osmosis Med provide education to healthcare students. Epocrates, UpToDate, and Drugs.com provide clinical and drug info for providers