MNT II: Billing and Coding Exam
Questions and Answers 100% Pass
Health care provider or supplier agrees (or is required by law to accept the third party
payer-approved amount as full payment for covered services and not to bill the client
for any more than the deductible and coinsurance. - ✔✔Accept Assignment
A group of care providers who give coordinate care and chronic disease management,
and thereby improve the quality of care patients get. The organization's payment is tied
to achieving health care quality goals and outcomes that result in cost saving. -
✔✔Accountable Care Organization
The amount of money charged by the health care provider or supplier for a certain
medical service or supply. This amount is often more than the amount Medicare or
third party payers approve. - ✔✔Actual charge
May also be known as a waiver of liability. A notice health care providers and suppliers
are required to give and have signed by Original Medicare when they believe that
Medicare will not cover the services or items and the person has no reason to know that
Medicare will not cover these services or items. If no ABN is not provided by provider,
the Medicare insured does not have to pay but if he/she signed an ABN for the
Katelyn Whitman, All Rights Reserved © 2025 1
,service/item then they are responsible and Medicare does not have to pay. -
✔✔Advance Beneficiary Notice (ABN)
Generic term referring to the maximum fee that a third party will use to reimburse a
provider for a given service. - ✔✔Allowable charge
A request by a beneficiary or a provider to have a review when health care services are
denied based on medical necessity or appropriateness, or improperly paid. - ✔✔Appeal
A referral that has been submitted to the patient's insurance company for approval for
the services requested to be performed. - ✔✔Authorization
Balance billing is the practice of billing a patient for charges not paid by his/her
insurance plan because the charges are in excess of covered amounts. Balance billing
amount will often be charges that are beyond the fee schedule or contract rate. -
✔✔Balance Bill
A person who is covered by the third party payer - ✔✔Beneficiary
The specified period of time during which charges for covered services must be
incurred in order to be eligible for payment by a third party payer. - ✔✔Benefit period
The reimbursement of health care providers (such as hospitals and physicians) on the
basis of expected costs for clinically-defined episodes of care. It has been described as a
"middle ground" between fee for service reimbursement (in which providers are paid
Katelyn Whitman, All Rights Reserved © 2025 2
, for each service rendered to a patient) and capitation (in which providers are paid a
"lump sum" per patient regardless of how many services the patient receives).
Bundled payments have been proposed in the health care reform debate in the United
States as a strategy for reducing health care costs. - ✔✔Bundled Payment
A payment arrangement for health care service providers based on a set amount for
enrolled persons assigned to them rather than a payment per service provided. The
provider is paid whether or not the enrolled person seeks care. - ✔✔Capitation
A payment system that measures the intensity of care and services required for each
patient, and translates these measures into the amount of reimbursement given to the
facility for care of a patient. Payment if linked to the intensity of resource use. - ✔✔Case
Mix Reimbursement System
An electronic list of a facility's services and supplies, billing codes and the associated
charges. The charge master must be kept updated to the latest codes and government
billing regulations for health claims. - ✔✔Charge Master
A request for payment for the service(s) provided by a health care provider. - ✔✔Claim
The 1500 claim form is the universal insurance claim form developed and approved by
the AMA and Centers for Medicare and Medicaid Services. This form is used by non-
institutional providers/suppliers to bill Medicare carriers, commercial/private
insurance and billing of some Medicaid State Agencies. - ✔✔1500 Claim Form
Katelyn Whitman, All Rights Reserved © 2025 3
Questions and Answers 100% Pass
Health care provider or supplier agrees (or is required by law to accept the third party
payer-approved amount as full payment for covered services and not to bill the client
for any more than the deductible and coinsurance. - ✔✔Accept Assignment
A group of care providers who give coordinate care and chronic disease management,
and thereby improve the quality of care patients get. The organization's payment is tied
to achieving health care quality goals and outcomes that result in cost saving. -
✔✔Accountable Care Organization
The amount of money charged by the health care provider or supplier for a certain
medical service or supply. This amount is often more than the amount Medicare or
third party payers approve. - ✔✔Actual charge
May also be known as a waiver of liability. A notice health care providers and suppliers
are required to give and have signed by Original Medicare when they believe that
Medicare will not cover the services or items and the person has no reason to know that
Medicare will not cover these services or items. If no ABN is not provided by provider,
the Medicare insured does not have to pay but if he/she signed an ABN for the
Katelyn Whitman, All Rights Reserved © 2025 1
,service/item then they are responsible and Medicare does not have to pay. -
✔✔Advance Beneficiary Notice (ABN)
Generic term referring to the maximum fee that a third party will use to reimburse a
provider for a given service. - ✔✔Allowable charge
A request by a beneficiary or a provider to have a review when health care services are
denied based on medical necessity or appropriateness, or improperly paid. - ✔✔Appeal
A referral that has been submitted to the patient's insurance company for approval for
the services requested to be performed. - ✔✔Authorization
Balance billing is the practice of billing a patient for charges not paid by his/her
insurance plan because the charges are in excess of covered amounts. Balance billing
amount will often be charges that are beyond the fee schedule or contract rate. -
✔✔Balance Bill
A person who is covered by the third party payer - ✔✔Beneficiary
The specified period of time during which charges for covered services must be
incurred in order to be eligible for payment by a third party payer. - ✔✔Benefit period
The reimbursement of health care providers (such as hospitals and physicians) on the
basis of expected costs for clinically-defined episodes of care. It has been described as a
"middle ground" between fee for service reimbursement (in which providers are paid
Katelyn Whitman, All Rights Reserved © 2025 2
, for each service rendered to a patient) and capitation (in which providers are paid a
"lump sum" per patient regardless of how many services the patient receives).
Bundled payments have been proposed in the health care reform debate in the United
States as a strategy for reducing health care costs. - ✔✔Bundled Payment
A payment arrangement for health care service providers based on a set amount for
enrolled persons assigned to them rather than a payment per service provided. The
provider is paid whether or not the enrolled person seeks care. - ✔✔Capitation
A payment system that measures the intensity of care and services required for each
patient, and translates these measures into the amount of reimbursement given to the
facility for care of a patient. Payment if linked to the intensity of resource use. - ✔✔Case
Mix Reimbursement System
An electronic list of a facility's services and supplies, billing codes and the associated
charges. The charge master must be kept updated to the latest codes and government
billing regulations for health claims. - ✔✔Charge Master
A request for payment for the service(s) provided by a health care provider. - ✔✔Claim
The 1500 claim form is the universal insurance claim form developed and approved by
the AMA and Centers for Medicare and Medicaid Services. This form is used by non-
institutional providers/suppliers to bill Medicare carriers, commercial/private
insurance and billing of some Medicaid State Agencies. - ✔✔1500 Claim Form
Katelyn Whitman, All Rights Reserved © 2025 3
