CRCR UPDATED EXAMINERS TIPS QUESTIONS
AND ANSWERS SURE A+
✔✔Discounted fee-for-service - ✔✔A reimbursement methodology whereby a provider
agrees to provide service on a fee for service basis, but the fees are discounted by
certain packages
✔✔Eligibility - ✔✔Patient status regarding coverage for healthcare insurance benefits
✔✔First dollar coverage - ✔✔A healthcare insurance policy that has no deductible and
covers the first dollar of an insured's expenses
✔✔Gatekeeping - ✔✔A concept wherein the primary care physician provides all primary
patient care and coordinates all diagnostic testing and specialty referrals required for a
patient's medical care
✔✔Health plan - ✔✔an insurance company that provides for the delivery or payment of
healthcare services
✔✔Indemnity insurance - ✔✔negotiated healthcare coverage within a framework of fee
schedules, limitations, and exclusions that is offered by insurance companies or
benevolent associations
, ✔✔Medically necessary - ✔✔Healthcare services that are required to preserve or
maintain a person's health status in accordance with medical practice standards
✔✔Out-of-area benefits - ✔✔healthcare plan coverage allowed to covered persons for
emergency situations outside of the prescribed geographic area of the HMO
✔✔Out-of-pocket payments - ✔✔Cash payments made by the insured for services not
covered by the health insurance plan
✔✔Pre-admission review - ✔✔the practice of reviewing requests for inpatient admission
before the patient is admitted to ensure that the admission is medically necesary
✔✔Pre-existing condition limitation - ✔✔A restriction on payments for charges directly
resulting from a pre-existing health conditions
✔✔Same-day admission - ✔✔A cost containment practice that reduces a surgical
patient's inpatient stay by requiring that pre-procedure testing and preparation are
completed on an outpatient basis and the patient is admitted the same day as the
procedure
✔✔Self-insured - ✔✔Large employers who assume direct responsibility or risk for
paying employees' healthcare without purchasing health insurance
✔✔Subrogation - ✔✔Seeking, by legal or administrative means, reimbursement from
another party that is primarily responsible for a patient's medical expenses
✔✔Subscriber - ✔✔An employer, a union, or an association that contracts with an
insurance company for the healthcare plan it offers to eligible employees
✔✔Sub-specialist - ✔✔A healthcare professional who is recognized to have expertise in
a specialty of medicine or surgery
✔✔Third-part administrator (TPA) - ✔✔Provides services to employers or insurance
companies for utilization review, claims payment and benefit design
✔✔Third-party reimbursement - ✔✔A general term used for the healthcare benefit
payments - used to identify that for benefit plans there are three parties in the
transaction
✔✔Usual, customary, and reasonable (UCR) - ✔✔Health insurance plan reimbursement
methodology that limits payment to the lower billed charges, the provider's customary
charge, or the prevailing charge for the service in the community
AND ANSWERS SURE A+
✔✔Discounted fee-for-service - ✔✔A reimbursement methodology whereby a provider
agrees to provide service on a fee for service basis, but the fees are discounted by
certain packages
✔✔Eligibility - ✔✔Patient status regarding coverage for healthcare insurance benefits
✔✔First dollar coverage - ✔✔A healthcare insurance policy that has no deductible and
covers the first dollar of an insured's expenses
✔✔Gatekeeping - ✔✔A concept wherein the primary care physician provides all primary
patient care and coordinates all diagnostic testing and specialty referrals required for a
patient's medical care
✔✔Health plan - ✔✔an insurance company that provides for the delivery or payment of
healthcare services
✔✔Indemnity insurance - ✔✔negotiated healthcare coverage within a framework of fee
schedules, limitations, and exclusions that is offered by insurance companies or
benevolent associations
, ✔✔Medically necessary - ✔✔Healthcare services that are required to preserve or
maintain a person's health status in accordance with medical practice standards
✔✔Out-of-area benefits - ✔✔healthcare plan coverage allowed to covered persons for
emergency situations outside of the prescribed geographic area of the HMO
✔✔Out-of-pocket payments - ✔✔Cash payments made by the insured for services not
covered by the health insurance plan
✔✔Pre-admission review - ✔✔the practice of reviewing requests for inpatient admission
before the patient is admitted to ensure that the admission is medically necesary
✔✔Pre-existing condition limitation - ✔✔A restriction on payments for charges directly
resulting from a pre-existing health conditions
✔✔Same-day admission - ✔✔A cost containment practice that reduces a surgical
patient's inpatient stay by requiring that pre-procedure testing and preparation are
completed on an outpatient basis and the patient is admitted the same day as the
procedure
✔✔Self-insured - ✔✔Large employers who assume direct responsibility or risk for
paying employees' healthcare without purchasing health insurance
✔✔Subrogation - ✔✔Seeking, by legal or administrative means, reimbursement from
another party that is primarily responsible for a patient's medical expenses
✔✔Subscriber - ✔✔An employer, a union, or an association that contracts with an
insurance company for the healthcare plan it offers to eligible employees
✔✔Sub-specialist - ✔✔A healthcare professional who is recognized to have expertise in
a specialty of medicine or surgery
✔✔Third-part administrator (TPA) - ✔✔Provides services to employers or insurance
companies for utilization review, claims payment and benefit design
✔✔Third-party reimbursement - ✔✔A general term used for the healthcare benefit
payments - used to identify that for benefit plans there are three parties in the
transaction
✔✔Usual, customary, and reasonable (UCR) - ✔✔Health insurance plan reimbursement
methodology that limits payment to the lower billed charges, the provider's customary
charge, or the prevailing charge for the service in the community
