My AAPC CPB - Chapter 12 Review Questions & Answers

The term for the set payment that the member pays to the healthcare provider on the day of service is the: a. office visit fee. b. co-insurance. c. copay. d. co-signer. - ANSWERSc. copay. Blue Cross/Blue Shield identifies the individual or employee who pays for healthcare insurance coverage as the: a. Member b. Group c. Subscriber d. Payer - ANSWERSc. Subscriber What information can be found on the Blue Cross/Blue Shield insurance identification card? I. Type of plan II. Subscriber's address and phone number III. ID number IV. Group number V. Name of primary care provider VI. Phone number for Member Services/Benefits questions VII. Mailing address of BC/BS office a. II, V, VII b. I, III, IV, VI c. V, VI, VII d. I, III, IV, VI, VII - ANSWERSd. I, III, IV, VI, VII The Blue Cross/Blue Shield member's insurance card will list which of the following: a. provider's name. b. type of insurance. c. type of plan. d. both b & c. - ANSWERSd. both b & c. The document reporting the benefits applied to a Blue Cross/Blue Shield claim is the: a. Explanation of Payment (EOP). b. Explanation of Benefits (EOB). c. Explanation of Coverage (EOC). d. None of the above. - ANSWERSb. Explanation of Benefits (EOB). Blue Cross and Blue Shield is the: a. oldest and smallest family of health benefits companies in the United States. b. newest and largest family of health benefits companies in the United States. c. oldest and largest family of health benefits companies in the United States. d. only health insurance company promoting preferred provider organizations. - ANSWERSc. oldest and largest family of health benefits companies in the United States. Blue Cross/Blue Shield offers which type of Medicare plan? a. Medicare Plus b. Medicare Advantage c. Medicare Part G d. Medicare Add-on - ANSWERSb. Medicare Advantage Developing a strong relationship with the insurance Provider Representative will result in: a. difficulty resolving claim payment issues. b. problems with provider credentialing. c. increased ability to resolve billing, contracting issues that may arise. d. both a & b. - ANSWERSc. increased ability to resolve billing, contracting issues that may arise. A Blue Cross/Blue Shield insurance plan that allows members to choose any provider, but offers higher levels of coverage when members obtain services from network providers would be an example of: a. Health Maintenance Organization (HMO) b. Point of Service (POS) c. Preferred Provider Organization (PPO) d. Indemnity - ANSWERSc. Preferred Provider Organization (PPO) Tony's Blue Cross/Blue Shield healthcare insurance policy states that he must seek healthcare services only from providers that are part of a specific network. What type of Blue Cross/Blue Shield plan does Tony have? a. POS b. HMO c. Fee-for-Service d. Indemnity - ANSWERSb. HMO Obtaining approval from the insurance payer before a procedure is performed is known as: a. prior authorization. b. prior approval. c. initial approval. d. initial authorization. - ANSWERSa. prior authorization. Blue Cross/Blue Shield received a claim on 4/15/19 for services performed on 3/15/18. The claim would be denied because: a. the claim did not have correct provider number. b. claim was filed after the timely filing limit. c. service was not a covered benefit. d. service did not meet medical necessity. - ANSWERSb. claim was filed after the timely filing limit. Best practice to prevent receiving a denial due to coverage termination would be to: a. call each payer every month to ensure that each scheduled patient is still covered. b. verify coverage prior to the patient's scheduled appointment. c. verify coverage after the patient is seen by provider. d. contact each patient every month to verify insurance coverage. - ANSWERSb. verify coverage prior to the patient's scheduled appointment. Carl has enrolled in a healthcare insurance plan that allows him to choose to have services provided within the Blue Cross/Blue Shield network or outside of the network. What type of plan best describes Carl's insurance coverage? a. Indemnity b. Point of Service c. Health Maintenance Organization (HMO) d. Preferred Provider Organization (PPO) - ANSWERSb. Point of Service The provider, hospital, or entity that agrees to provide healthcare services to an insurance plan's enrollees is a: a. contracted provider. b. pre-determined provider. c. service provider. d. participating provider. - ANSWERSd. participating provider.