MEDICAL BILLING AND CODING PRACTICE
TEST QUESTIONS WITH ACCURATE
ANSWERS (GRADE A+) – LATEST VERSION
Medical Insurance - ANSWER: Financial plan (the payer) that covers the
cost of hospital and medical care
Policyholder - ANSWER: Person who buys an insurance plan; the
insured, subscriber, or guarantor
Health Plan - ANSWER: Individual or group plan that provides or pays
for the cost of medical care
Benefits - ANSWER: What a health plan pays for services covered in an
insurance policy; listed in the schedule of benefits.
Medical Necessity - ANSWER: Reasonable services of provider (doctor
or facility) consistent with professional medical standards.
Covered Services - ANSWER: Determined as being medically
,necessary and both reasonable and consistent with the standards for the
diagnosis or treatment of injury or illness.
Non-covered Services - ANSWER: Medical procedures not covered in
a plans benefits.
Individual Health Plan (I H P) - ANSWER: contract between individual
and the plan known as direct pay.
Group Health Plan (G H P) - ANSWER: contract between an employer
or organization and the plan, the group members are insured as
"subscribers".
Disability Insurance - ANSWER: Replaces income lost because the
insured cannot work
Workers' Compensation Insurance - ANSWER: Provides benefits for an
insured injured on the job
Indemnity Insurance - ANSWER: Payment method is fee-for-service
based on the contract's schedule of benefits,fee is paid AFTER the
,patient receives services from the physician.
Managed care - ANSWER: A system that combines the financing and
the delivery of appropriate, cost-effective health care services to its
members.
Premium - ANSWER: Periodic payment the patient is required to make
to keep the policy in effect.
Deductible - ANSWER: Amount that the insured pays on covered services
before benefits begin.
Coinsurance - ANSWER: Percentage of each claim that the insured
pays; states the health plan's percentage of the charge, followed by the
insured's percentage.
Health Maintenance Organizations (HMOs) - ANSWER: A manged
health care system in which providers agree to offer healthcare to the
organization's members for fixed periodic payments from the plan.
capitation Method - ANSWER: a fixed prepayment made to the medical
, provider for all necessary contracted services provided to each patient
who is a plan member no matter how much medical care is received
during the determined time period.
Per member per month, (PMPM) - ANSWER: (per member per
month): The "capitated rate" Capitation this amount is paid to the health
care provider based on the schedule of benefits, no matter how much
medical care is received during the determined time period.
Point of Service Plan (PPO) - ANSWER: Combines features of both
HMOs and PPOs Also called an "open access HMO "Allows members
to see providers in or out of HMO's network Members pay more for
out-of-network providers.
Preferred Provider Organizations (PPO) - ANSWER: A managed care
organization structured as a network of health care providers who agree
to perform services for plan members at discounted fees; usually, plan
members can receive services from non-network providers for a higher
charge. PPOs control the cost of health care by:
Directing patients' choices of providers
Controlling use of services
Requiring preauthorization for services
Requiring Cost-sharing
TEST QUESTIONS WITH ACCURATE
ANSWERS (GRADE A+) – LATEST VERSION
Medical Insurance - ANSWER: Financial plan (the payer) that covers the
cost of hospital and medical care
Policyholder - ANSWER: Person who buys an insurance plan; the
insured, subscriber, or guarantor
Health Plan - ANSWER: Individual or group plan that provides or pays
for the cost of medical care
Benefits - ANSWER: What a health plan pays for services covered in an
insurance policy; listed in the schedule of benefits.
Medical Necessity - ANSWER: Reasonable services of provider (doctor
or facility) consistent with professional medical standards.
Covered Services - ANSWER: Determined as being medically
,necessary and both reasonable and consistent with the standards for the
diagnosis or treatment of injury or illness.
Non-covered Services - ANSWER: Medical procedures not covered in
a plans benefits.
Individual Health Plan (I H P) - ANSWER: contract between individual
and the plan known as direct pay.
Group Health Plan (G H P) - ANSWER: contract between an employer
or organization and the plan, the group members are insured as
"subscribers".
Disability Insurance - ANSWER: Replaces income lost because the
insured cannot work
Workers' Compensation Insurance - ANSWER: Provides benefits for an
insured injured on the job
Indemnity Insurance - ANSWER: Payment method is fee-for-service
based on the contract's schedule of benefits,fee is paid AFTER the
,patient receives services from the physician.
Managed care - ANSWER: A system that combines the financing and
the delivery of appropriate, cost-effective health care services to its
members.
Premium - ANSWER: Periodic payment the patient is required to make
to keep the policy in effect.
Deductible - ANSWER: Amount that the insured pays on covered services
before benefits begin.
Coinsurance - ANSWER: Percentage of each claim that the insured
pays; states the health plan's percentage of the charge, followed by the
insured's percentage.
Health Maintenance Organizations (HMOs) - ANSWER: A manged
health care system in which providers agree to offer healthcare to the
organization's members for fixed periodic payments from the plan.
capitation Method - ANSWER: a fixed prepayment made to the medical
, provider for all necessary contracted services provided to each patient
who is a plan member no matter how much medical care is received
during the determined time period.
Per member per month, (PMPM) - ANSWER: (per member per
month): The "capitated rate" Capitation this amount is paid to the health
care provider based on the schedule of benefits, no matter how much
medical care is received during the determined time period.
Point of Service Plan (PPO) - ANSWER: Combines features of both
HMOs and PPOs Also called an "open access HMO "Allows members
to see providers in or out of HMO's network Members pay more for
out-of-network providers.
Preferred Provider Organizations (PPO) - ANSWER: A managed care
organization structured as a network of health care providers who agree
to perform services for plan members at discounted fees; usually, plan
members can receive services from non-network providers for a higher
charge. PPOs control the cost of health care by:
Directing patients' choices of providers
Controlling use of services
Requiring preauthorization for services
Requiring Cost-sharing
