NHA CCMA Study Guide

Insurance Terminology

  • Advance Beneficiary Notice (ABN):

    • Form given to patients indicating that Medicare may not pay for certain services.

  • Allowed Amount:

    • Maximum amount paid by a third-party payer for a procedure.

  • Copayment:

    • Fixed amount paid at the time of medical service.

  • Coinsurance:

    • Cost-sharing arrangement where the policyholder and insurer split covered losses (e.g., 80% insurer, 20% policyholder).

  • Deductible:

    • Amount a patient must pay before insurance begins covering costs.

  • Explanation of Benefits (EOB):

    • Statement detailing services paid, denied, or adjusted by the insurer. Includes deductible and coinsurance information.

  • Participating Provider (PAR):

    • Providers who agree to accept the insurer's approved fees and write off the difference from billed amounts.

Types of Insurance Plans

  • Federal and State Plans:

    • Medicare: Covers those generally age 65 and older. Part A covers hospitalization, Part B covers routine office visits.

    • Tricare: For dependents of military personnel.

    • CHAMPVA: For surviving spouses/children of veterans with service-related disabilities.

    • Medicaid: Assists low-income individuals/families.

    • Managed Care Plans: Bundled payment for health services through a defined network.

    • Workers’ Compensation: Covers wages and medical costs from work-related injuries or diseases.

CMS-1500 Form

  • Used for reimbursement claims by healthcare providers.

  • Structure:

    • Section 1: Carrier Block (insurance carrier details).

    • Section 2: Patient/Insured Section (patient demographics).

    • Section 3: Physician/Supplier Section (provider details).

Positions for Physical Examinations

  • Supine Position: Lying flat on the back.

  • Dorsal Recumbent Position: Lying on the back with the knees bent.

  • Sims' Position: Lying on the left side with legs positioned.

  • Knee-Elbow Position: Kneeling with upper body bent forward.

  • Fowler's Position: Sitting with an angle of 90 degrees.

  • Lithotomy Position: Lying flat with feet in stirrups.

Controlled Substances Schedules (CSA)

  • Schedule I: High abuse potential, no medical use (e.g., heroin, LSD).

  • Schedule II: High abuse potential, with severe dependence (e.g., morphine); requires handwritten prescription with no refills.

  • Schedule III: Moderate-low abuse potential, up to 5 refills in 6 months (e.g., ketamine).

  • Schedule IV: Low abuse potential, similar refills as Schedule III (e.g., diazepam).

  • Schedule V: Limited quantities of narcotics; can refill up to 5 times in 6 months.

Household Measurements

  • Conversions:

    • 1 tsp = 15 drops.

    • 1 tbsp = 15 mL.

    • 1 fl oz = 30 mL, etc.

Routes of Administration (Parenteral)

  • Various routes and formulations including:

    • Epidural: Injected into the spine.

    • Intravenous (IV): Via major veins.

    • Subcutaneous (SC): Under the skin.

Vitamins and Nutrition

  • Fat-soluble: A, D, E, K

  • Water-soluble: B-complex vitamins, C

Erikson's Psychosocial Development Stages

  • Trust vs. Mistrust

  • Autonomy vs. Shame/Doubt

  • Initiative vs. Guilt

  • Industry vs. Inferiority

  • Identity vs. Role Confusion

  • Intimacy vs. Isolation

  • Generativity vs. Stagnation

  • Ego Integrity vs. Despair

Common Defense Mechanisms with Examples

  • Apathy: Indifference towards others.

  • Denial: Refusing to accept reality (e.g., “I don’t need that test”).

  • Projection: Transferring one's feelings to someone else.

  • Regression: Reverting to earlier behaviors (e.g., temper tantrums).

Body Directional Terms

  • Superior: Above (e.g., esophagus is superior to the stomach).

  • Inferior: Below (e.g., bladder is inferior to kidneys).

  • Anterior: Front (e.g., sternum anterior to spine).

  • Posterior: Back (e.g., sacrum posterior to pubis).

Planes of the Body

  • Sagittal: Divides left and right.

  • Coronal: Divides front and back.

  • Transverse: Divides upper and lower.

Body Cavities

  • Cranial Cavity: Contains the brain.

  • Thoracic Cavity: Contains heart and lungs.

  • Abdominal Cavity: Contains digestive organs.

  • Pelvic Cavity: Contains reproductive organs.

Blood Circulation

  • Systemic Circulation: Pumps oxygenated blood to the body.

  • Pulmonary Circulation: Moves deoxygenated blood to the lungs.

Homeostasis

  • Maintenance of internal stability via the nervous and endocrine systems.

Chain of Infection

  • Links: Infectious agent → Reservoir → Portal of exit → Mode of transmission → Portal of entry → Susceptible host.

Average Heart Rates by Age

  • Newborn: 120-160/min

  • Adult: 60-100/min

Vital Signs: Blood Pressure and Respiration

  • Blood Pressure: Normal reading is 100/60 to 140/80 mm Hg.

Prescription Parts and Guidelines

  • Essential components include prescriber info, patient data, medication, instructions, and signatures.

Medical Necessity and Coding

  • ICD-10-CM: Used for diagnosis; CPT codes for procedures.

Common Laboratory Test Values

  • Normal ranges for Hemoglobin, Hematocrit, Glucose, etc.