MedCerts CMAA Objective Five - Patient
Education with Complete Solutions
Advanced Beneficiary Notice (ABN) - ANSWER-If a provider believes that a particular
service or procedure may be denied as non-covered or not medically necessary for a
Medicare patient, they are required to provide this written form to the patient prior to
providing the service or performing the procedure. (providers often use this for non-
Medicare patients as well even though other payers do not require it.)
Assignment of Benefits (AOB) - ANSWER-Form that the patient signs authorizing the
health insurance carrier to pay the provider directly for procedures and services
rendered.
Birthday Rule - ANSWER-when a child has 2 health insurance policies (one through
each parent), the question of which insurance is the primary policy is determined by
which parent's birthday falls first in the calendar year (not by year of birth). The other
policy is therefore secondary.
Coinsurance - ANSWER-a percentage of the bill that a patient has to pay for certain
services. If the patient has more than one insurance, it is possible that the "secondary"
insurance will pick up the ___ amount (most often 20% or 30% of the bill), after the
"primary" insurance has paid their portion (70% or 80%)
Coordination of Benefits (COB) - ANSWER-If a patient has more than one insurance
policy, this process safeguards against having both policies pay as the primary
insurance, thus reimbursing the provider more than 100% of the allowed amount.
Copay - ANSWER-a predetermined flat-rate fee that you pay the provider, at the time of
service. (The amount may depend on the service: office visit, prescription, ER, etc.)
Deductible - ANSWER-a specified amount of money you must pay out of pocket before
your insurance will cover services. ___ are usually set on a yearly basis for individuals
or families.
DNR (do not resuscitate) order - ANSWER-A legal document indicating to withhold
cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS), based
on the wishes of the patient, in the event they stop breathing or their heart stops. This is
also known as a "No Code" order.
Explanation of Benefits (EOB) - ANSWER-A document from an insurance company that
describes services billed, benefit limits, payments made, and denials. Medicare patients
receive this information in the form of the Medicare Summary Notice (MSN).
Education with Complete Solutions
Advanced Beneficiary Notice (ABN) - ANSWER-If a provider believes that a particular
service or procedure may be denied as non-covered or not medically necessary for a
Medicare patient, they are required to provide this written form to the patient prior to
providing the service or performing the procedure. (providers often use this for non-
Medicare patients as well even though other payers do not require it.)
Assignment of Benefits (AOB) - ANSWER-Form that the patient signs authorizing the
health insurance carrier to pay the provider directly for procedures and services
rendered.
Birthday Rule - ANSWER-when a child has 2 health insurance policies (one through
each parent), the question of which insurance is the primary policy is determined by
which parent's birthday falls first in the calendar year (not by year of birth). The other
policy is therefore secondary.
Coinsurance - ANSWER-a percentage of the bill that a patient has to pay for certain
services. If the patient has more than one insurance, it is possible that the "secondary"
insurance will pick up the ___ amount (most often 20% or 30% of the bill), after the
"primary" insurance has paid their portion (70% or 80%)
Coordination of Benefits (COB) - ANSWER-If a patient has more than one insurance
policy, this process safeguards against having both policies pay as the primary
insurance, thus reimbursing the provider more than 100% of the allowed amount.
Copay - ANSWER-a predetermined flat-rate fee that you pay the provider, at the time of
service. (The amount may depend on the service: office visit, prescription, ER, etc.)
Deductible - ANSWER-a specified amount of money you must pay out of pocket before
your insurance will cover services. ___ are usually set on a yearly basis for individuals
or families.
DNR (do not resuscitate) order - ANSWER-A legal document indicating to withhold
cardiopulmonary resuscitation (CPR) or advanced cardiac life support (ACLS), based
on the wishes of the patient, in the event they stop breathing or their heart stops. This is
also known as a "No Code" order.
Explanation of Benefits (EOB) - ANSWER-A document from an insurance company that
describes services billed, benefit limits, payments made, and denials. Medicare patients
receive this information in the form of the Medicare Summary Notice (MSN).
