ch 1,2,3 and HIPAA

What is adjudication

Process followed by health plans to examine claims and determine benefits

what is Authorization/Certification number

Number that is returned electronically by health plan to authorize referral request when preauthorization is required

what is birthday rule

Guidelines to determine which parent has primary insurance for a child-

- birth month comes first

what is breach

Impermissible use or disclosure under privacy rule that compromises security of PHI

what is business associate

Person or organization that preforms function or activity that is not part of its workforce

what is coordination of Benefits

A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.

what is co-insurance

The portion of charges that an insured person must pay for healthcare services after payment of the deductible amount;

usually stated as a percentage.

what is deductible

An amount that an insured person must pay, usually on an annual basis, for healthcare services before a health plan's payment begins.

what is de-identified also known as what

Medical data from which individual identifiers have been removed;

also known as a redacted or blinded record.

what is dependents

Person other than insured who is covered under health plan

what is direct provider

professional who directly treats the patient

what is documentation

organizing a patient's health record in chronological order using systemic, consistent method

what is encounter form

A list of the diagnosis, procedures, and charges for a patient's visit, also called the superbill.

what is encryption

- the process of encoding information in such a way that only the person with the key can decode it

what is established patient

Individual who has received professional services from provider within the past 3 years

what is etiquette

standards of professional behavior

what is financial policy

A practice's rules governing payment for medical services from patients.

what are the four types of insurance plans

HMO - health maintenance organization

PPO - preferred provider organization

HSA - health savings account

POS - Point of service

fee for service

what is guarantor

A person who is financially responsible for the bill from the practice.

what are the parts of medicare plans

Part A/B Hospital and Medical Insurance,

Part C medicare advantage,

Part D- Prescription Drug Coverage

what is a new patient

Havent recieved services from a provider within the past three years

what is payer

person or organization that pays

what is policyholder

person who buys an insurance plan

what is schedule of benefits

Document that outlines the fees associated with each type or health care services covered by your plan

what is subpoena duces tecum

if the court requires the witness to bring certain evidence

what is EHR

EHR - Electronic Health Record: shareable record of a patient's overall health information.

Designed to be shared across multiple providers, hospitals, etc

what is EMR

EMR - Electronic Medical Record

A digital version of a patient's chart in a single provider's office or clinic.

Used within one practice or facility only.

what are the three HIPAA rules

privacy, security, electronic code set standards

what is the privacy rule of HIPAA

the privacy requirements cover patients health information

what is the security rule of HIPAA

states the administrative, technical and physical safeguards that are required to protect patients health info

what is the Electronic Code Set Standards: of HIPAA

these standard require every provider who does business electronically to use the same healthcare transactions, code sets, and identifiers

what are the 7 HIPAA regulations

1. HIPAA is designed to improve the efficiency and effectiveness of the health care system.

2. HIPAA: Health Insurance Portability and Accountability Act of 1996

3. Breach of HIPAA compliance (giving away information) - you can be fined $250,000.00 and 10 years in prison

4. A patient's information can be shared when it is directly related to treatment

5. Confidentiality applies to all medical and personal information.

6. Exceptions to confidentiality include gunshot wounds, communicable diseases, rape, abuse, and vital statistics.

7. The Notice of Privacy Practices is offered to the patient during their first visit

what are the three HIPAA covered entities

Health Plans/Payers

Clearinghouses

Providers

what the do the parts in SOAP mean

Subjective - CC, symptoms, signs

o Objective - observable, measurable signs

o Assessment - provider's interpretation of the subjective and objective findings, diagnosis

o Plan - treatment, prescriptions, course of action

CE stands for?

covered entitiy

CMS stands for?

centers for medicare & medicaid services

EHR stands for?

electronic health records

HIPAA stands for?

health insurance portability and accountability act

nonPAR stands for ?

non participating

NPI stands for ?

national provider identifier

OCR stands for?

optical character recognition

OIG stands for?

office of inspector general

PHI stands for?

Protected Health Information

TPO stands for?

Treatment, payment, and healthcare operations

what are some examples of PHI

Name, Address, phone #, Driver's License, SSN, Medical Records, Billing, Medical record number

anything that identifies them, relates to their health, healthcare, or payments

What federal agency runs Medicare and Medicaid?

CMS- Centers for Medicare and MEdicaid Services

What is a compliance plan? How many elements are in the plan?

a structured set of policies, procedures that a medical practice uses to make sure it follows laws/standards

7 elements

what is patient information form

Form that includes a patient's personal, employment, and insurance company data needed to complete a health claim;

also known as a registration form.

Can you release PHI using the rule of TPO?

yes

Assignment of Benefits - what is the purpose?

To claim medical services and obtain benefits from pt's insurance plan

what is assinment of benefits

Authorization by a policyholder that allows a health plan to pay benefits directly to a provider.

What is the 1st step in establishing financial responsibility for the patient's visit

verifying their eligibility, telling them the benefits?

Verify the payers rules for the medical necessity of the planned service

Difference between a Prospective and Retrospective Payments

Amount of payment is -before; prospective,

retrospective;-after means based on the actual service

Elements of CDHP Plan

Consumer driven health plan

1. High deductible plan (HDHP)

2. And a special pre-tax savings plan/account

what is revenue cycle

All administrative and clinical functions that help capture and collect patients' payments for medical.