Healthcare Reimbursement Ch. 3 Study
Questions and Correct Answers
Actual charge ✅Amount provider actually bills a patient, which may differ from the
allowable charge.
Adjudication ✅The determination of the reimbursement payment based on the
member's insurance benefits.
Adjustment ✅Amount that healthcare insurers deduct providers' payments per
contracted discounts.
Adverse selection ✅Enrollment of excessive proportion of persons with poor health
status in a healthcare plan or healthcare organization.
Allowable charge ✅Average or maximum amount the third-party payer will reimburse
providers for the service.
Appeal ✅Request for reconsideration of denial of coverage or rejection of claim.
Assignment of benefits ✅1. A contract between a physician and Medicare in which the
physician agrees to bill Medicare directly for covered services, to bill the beneficiary only
for any coinsurance or deductible that may be applicable, and to accept the Medicare
payment as payment in full. Medicare usually pays 80 percent of approved amount
directly to the provider of services after the beneficiary meets the annual Part B
deductible. The beneficiary pays the other 20 percent (coinsurance). 2. Contract
between a health provider and a health insurer in which the provider directly bills the
health insurer on behalf of the patient or client and the health insurer makes payment
directly to the provider. Provider agrees to accept insurer's allowance (allowable charge)
as full payment for covered services, less the patient's cost sharing, such as
deductibles, co-payments, and coinsurance.
Benefit ✅Healthcare service for which the healthcare insurance company will pay.
Benefit cap ✅Total dollar amount that a healthcare insurance company will pay for
covered healthcare services during a specified time period, such as a year or lifetime.
Benefit period ✅Length of time that a health insurance policy will pay benefits for the
member, family, and dependents.
Catastrophic expense limit ✅Specific amount, in a certain timeframe, such as one
year, beyond which all covered healthcare services for that policyholder or dependent
are paid at 100 percent by the healthcare insurance plan.
, Center of excellence ✅Healthcare organization that performs high volumes of a
service with correspondingly high quality; often recognized by medical peers for its
expertise, cost-effectiveness, and superior outcomes. Health insurers may negotiate
discounted rates at the organization for the service. To receive full coverage for the
service, insureds may be required to receive their service at the healthcare
organization.
Certificate holder ✅Member of a group for which the employer or association has
purchased group healthcare insurance.
Certificate number ✅Unique number identifying the holder of a healthcare insurance
policy.
Certificate of insurance ✅Formal contract between healthcare insurance company and
individuals or groups purchasing the healthcare insurance, detailing the provisions of
the healthcare insurance policy.
Claim ✅Request for payment, or itemized statement of healthcare services and their
costs, provided by a hospital, physician's office, or other healthcare provider.
Claim attachment ✅Documentation of supplemental information that assists in the
understanding of specific services received by an individual and in the determination of
payment.
Claim submission ✅Process of transmitting claims requesting payment to payers.
Clean claim ✅Request for payment that contains only accurate information (no errors
in data).
Clearinghouse ✅Entity that acts as an intermediary between providers and payers and
that converts health data into nonstandardized formats, such as paper, into
standardized electronic formats for processing.
Coinsurance ✅Cost sharing in which the policy or certificate holder pays a
preestablished percentage of eligible expenses after the deductible has been met. The
percentage may vary by type or site of service.
Consumer-directed (consumer-driven) healthcare plan (CDHP) ✅Form of healthcare
insurance characterized by influencing patients and clients to select cost-efficient
healthcare through the provision of information about health benefit packages and
through financial incentives.
Contracted discount rate ✅Type of fee-for-service reimbursement in which the third-
party payer has negotiated a reduced (discounted) fee for its covered insureds.
Questions and Correct Answers
Actual charge ✅Amount provider actually bills a patient, which may differ from the
allowable charge.
Adjudication ✅The determination of the reimbursement payment based on the
member's insurance benefits.
Adjustment ✅Amount that healthcare insurers deduct providers' payments per
contracted discounts.
Adverse selection ✅Enrollment of excessive proportion of persons with poor health
status in a healthcare plan or healthcare organization.
Allowable charge ✅Average or maximum amount the third-party payer will reimburse
providers for the service.
Appeal ✅Request for reconsideration of denial of coverage or rejection of claim.
Assignment of benefits ✅1. A contract between a physician and Medicare in which the
physician agrees to bill Medicare directly for covered services, to bill the beneficiary only
for any coinsurance or deductible that may be applicable, and to accept the Medicare
payment as payment in full. Medicare usually pays 80 percent of approved amount
directly to the provider of services after the beneficiary meets the annual Part B
deductible. The beneficiary pays the other 20 percent (coinsurance). 2. Contract
between a health provider and a health insurer in which the provider directly bills the
health insurer on behalf of the patient or client and the health insurer makes payment
directly to the provider. Provider agrees to accept insurer's allowance (allowable charge)
as full payment for covered services, less the patient's cost sharing, such as
deductibles, co-payments, and coinsurance.
Benefit ✅Healthcare service for which the healthcare insurance company will pay.
Benefit cap ✅Total dollar amount that a healthcare insurance company will pay for
covered healthcare services during a specified time period, such as a year or lifetime.
Benefit period ✅Length of time that a health insurance policy will pay benefits for the
member, family, and dependents.
Catastrophic expense limit ✅Specific amount, in a certain timeframe, such as one
year, beyond which all covered healthcare services for that policyholder or dependent
are paid at 100 percent by the healthcare insurance plan.
, Center of excellence ✅Healthcare organization that performs high volumes of a
service with correspondingly high quality; often recognized by medical peers for its
expertise, cost-effectiveness, and superior outcomes. Health insurers may negotiate
discounted rates at the organization for the service. To receive full coverage for the
service, insureds may be required to receive their service at the healthcare
organization.
Certificate holder ✅Member of a group for which the employer or association has
purchased group healthcare insurance.
Certificate number ✅Unique number identifying the holder of a healthcare insurance
policy.
Certificate of insurance ✅Formal contract between healthcare insurance company and
individuals or groups purchasing the healthcare insurance, detailing the provisions of
the healthcare insurance policy.
Claim ✅Request for payment, or itemized statement of healthcare services and their
costs, provided by a hospital, physician's office, or other healthcare provider.
Claim attachment ✅Documentation of supplemental information that assists in the
understanding of specific services received by an individual and in the determination of
payment.
Claim submission ✅Process of transmitting claims requesting payment to payers.
Clean claim ✅Request for payment that contains only accurate information (no errors
in data).
Clearinghouse ✅Entity that acts as an intermediary between providers and payers and
that converts health data into nonstandardized formats, such as paper, into
standardized electronic formats for processing.
Coinsurance ✅Cost sharing in which the policy or certificate holder pays a
preestablished percentage of eligible expenses after the deductible has been met. The
percentage may vary by type or site of service.
Consumer-directed (consumer-driven) healthcare plan (CDHP) ✅Form of healthcare
insurance characterized by influencing patients and clients to select cost-efficient
healthcare through the provision of information about health benefit packages and
through financial incentives.
Contracted discount rate ✅Type of fee-for-service reimbursement in which the third-
party payer has negotiated a reduced (discounted) fee for its covered insureds.
