Free flashcards about health ins. process

Supplemental insurance plans for Medicare beneficiaries provide additional coverage for an individual receiving benefits under Medicare Part A.

Under the Medicaid program,medically needy describes people with high medical expenses and low financial resources who are not receiving cash assistance.

Under the Medicaid program,comprehensive health insurance coverage and free prescriptions are offered to pregnant women whose family income is below 133 percent of the poverty level.

Under RBRVS,the nationally uniform relative value is based on a:the geographic adjustment factor b:the uniform conversion factor c:the provider’s work,practice cost,and malpractice insurance costs d:the UCR,practice cost,and malpractice insurance costs

The purpose of the GPCI is to account for a:regional differences in costs b:changes in the cost of living index c:differences in relative work values d:none of the above

Which answer correclty lists the main method(s) payers use to pay providers?a:allowed charges b:allowed charges,contracted fee schedule,and capitation c:contracted fee schedule and capitation d:capitation and retrospective payments

The Medicare allowed charge for a procedure is $150,and PAR provider’s usual charge is $200. Image database What amount must the provider write off? a:$150 b:$100 c:$50 d:$30

The Medicare allowed charge is $240 and the PAR provider’s usual charge is $600. Database web application What amount does the patient pay? a:$192 b:$48 c:$480 d:$120

The deductibles,coinsurance,and copayments patients pay are called their a:excluded services b:out-of-pocket expenses c:capitation rate d:maximum benefit limit

If a nonparticipating provider’s usual fee is $600,the allowed amount is $300,and the balance billing is permitted,what amount is written off? a:$150 b:$480 c:$300 d:$0

A physician practice that uses a billing service to send its claims is the a:destination payer b:referring provider c:billing provider d:pay-to-provider

On a HIPAA claim,which of these is assigned to a claim by the sender? a:claim control number b:line item control number c:either a or b d:neither a or b

The provider who provides the procedure on a claim if other than the pay-to-provider is called the a:referring provider b:rendering provider c:billing provider d:primary provider

A physician’s state license number is an example of a(n) a:primary identification number b:pay-to-provider c:secondary identification number d: none of the above

A physician’s state license number is an example of a(n) a:primary identification number b:pay-to-provider c:secondary identification number d: none of the above

A payer’s automated claim edits may result in claim denial because of a:lack of eligibility for a reported service b:lack of medical necessity c:lack of required preauthorization d:any of the above

When a claim is pulled by a payer for a manual review, the provider may be asked to submit a:revised procedure codes b:a new diagnosis c:clinical documentation d:revised charges

The advantage(s) of EFT for practices is (are) a:funds are available immediately b:the transfer is less costly than check deposits c:neither a nor b d: both a and b

What document is used by the medical insurance specialist to update the patient billing program with the payer’s payments and the amount due from the patient? a:EFT b:RA c:IRA d:OIG

Eligible members of a capitated plan are listed on the a:patient medical record b:monthly enrollment list c:annual membership list d:none of the above

Stop-loss provisions protect providers against a:malpractice charges b:extreme financial loss c:loss of number of patients d:increases in premiums

Which section of a managed care participation contract covers balance-billing rules? a:introductory section b:managed care plan obligations c:physician’s responsibilities d: compensation and billing guidelines

Which section of a managed care participation contract covers referrals and preauthorization rules? a:introductory section b:managed care plan obligations c:physician’s responsibilities d:compensation and billing guidelines

A plan pays 50 percent of the provider’s usual charge and requires the copayment of $5 to be applied toward the provider’s payment.


Database graphic What does the plan pay the provider when the usual charge is $200? a:$145 b:$95 c:$45 d:none of the above

Anyone over age 65 who receives Social Security benefits is automatically a:enrolled in Medicare Part A b: eligible for Medicare Part B c:both a and b d: neither a nor b

People who are over age 65 who do not receive Social Security benefits may enroll in Medicare Part A by a:paying a deductible b:paying a premium c:paying into a Medical Savings Account d:enrolling in a Medicare HMO

Under the Medicare program,if the approved amount for a procedure is $100,the participating physician will be paid $100(by Medicare and the patient),and the nonparticipant who accepts assignment will be paid a:$115 b:$100 c:$95 d:$80

If a Medicare PAR physician thinks that a planned procedure will not be found medically necessary by Medicare and so will not be reimbursed,the patient is asked to sign a a:advance beneficiary notice b:notice of exclusions from Medicare benefits c:Medicar

If a Medicare PAR physician knows that a planned procedure (such as a screening test) is not covered under Medicare and so will not be reimbursed,the patient is asked to sign a a:advance beneficiary notice b:notice of exclusions from Medicare benefits c:M

The TRICARE program that offers an HMO-like plan requiring no annual deductible is a:TRICARE Standard b:TRICARE Prime c:TRICARE Extra d:none of the above

The TRICARE program that offers an alternative managed care plan to TRICARE Prime with no annual enrollment fee is a:TRICARE Standard b:TRICARE Extra c:CHAMPUS d:CHAMPVA

When a provider initially examines a worker’s compensation patient,what document must be filed with the state? a:final report b:admission of liability c:first report of injury d:vocational report

Social Security Disability Insurance provides compensation for lost wages to individuals who a:are qualified for welfare programs b:have contributed to Social Security c:either a or b d: neither a nor b

Which term describes the patient’s condition upon hospital admission? a:inpatient b:principal diagnosis c:admitting diagnosis d:principal procedure

Which term describes the patient’s condition that,after study,is established as the main reason for a hospital admission? a:inpatient b:principal diagnosis c:principal procedure d:admitting diagnosis

Which term describes the main service performed for the condition listed as the principal diagnosis for a hospital inpatient? a:primary procedure b:principal diagnosis c:admitting procedure d:principal procedure

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