Chapter 24 and 25 Health Insurance || All Answers are Flawless.
accept assignment correct answers participating physician's agreement to accept allowed charge
as full payment
Advance Beneficiary Notice (ABN) correct answers document used to notify a Medicare
beneficiary that it is either unlikely that Medicare will pay or certain that Medicare will not pay
for the service they are going to be provided. Beneficiaries are required to sign this document if
they wish to have the service with the understanding that they will be responsible for payment.
Affordable Care Act correct answers An expansion of medicaid, most of employers must provide
health insurance, have insurance or face surtax, prevents rejection based on pre-existing
condition. Also referred to as "Obamacare", signed into law in 2010.
allowed amount correct answers the maximum amount an insurer will pay for any given service.
assignment of benefits correct answers the authorization, by signature of the patient, for payment
to be made directly by the patient's insurance to the provider for services.
beneficiary correct answers person entitled to benefits of an insurance policy. This term is most
widely used by Medicare.
birthday rule correct answers a means to identify primary responsibility in insurance coverage;
identifies the primary insurance carrier when children have coverage through more than one
parent. The insurance of the parent with the birthday earliest in the year, month and day only, is
identified as the primary insurer. If both parents have the same birth date, the policy that has
been in effect the longest is the primary carrier.
capitation correct answers the health care provider is paid a fixed amount per member per month
for each patient who is a member of a particular insurance organization regardless of whether
services were provided.
,carrier correct answers A person whose genotype includes a gene that is not expressed in the
phenotype.
CMS-1500 correct answers the standard claim form designed by the Centers for Medicare and
Medicaid Services to submit physician services for third-party (insurance companies) payment;
the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper
claim is allowed.
coinsurance correct answers a percentage that a patient is responsible for paying for each service
after the deductible has been met.
conversion factor correct answers the dollar amount that converts the RVUs into a fee.
coordination of benefits correct answers when both spouses have health care insurance, the
policy provision that limits benefits to 100 percent of the cost; also known as dual coverage;
procedures insurers use to avoid duplication of payment on claims when the patient has more
than one policy. One insurer becomes the primary payer, and no more than 100 percent of the
costs are covered.
co-payment correct answers a specified amount the insured must pay toward the charge for
professional services rendered at the time of service.
deductible correct answers an amount to be paid before insurance will pay.
dependent correct answers person covered under a subscriber's insurance policy; refers to
spouses and dependent children.
Diagnosis-related groups (DRGs) correct answers method of determining reimbursement from
medical insurance according to diagnosis on a prospective basis.
,Exclusive Provider Organization (EPO) correct answers EPOs are like HMOs in that patients
must use their EPO's provider network when receiving care. There is no partial coverage for out-
of-network care.
explanation of benefits correct answers a printed description of the benefits provided by the
insurer to the beneficiary; provides information to the patient about how an insurance claim from
a health provider (such as a physician or hospital) was paid on their behalf.
fee-for-service correct answers payment for each service that is provided; individuals who
choose to pay high premiums so that they have the flexibility to seek medical care from health
care professionals of their choice.
fee schedule correct answers a list of predetermined payment amounts for professional services
provided to patients.
flexible spending arrangement (FSA) correct answers pretax funds set aside for use in payment
of medical services and supplies not covered by insurance; referred to as a cafeteria plan.
Qualified medical expenses are those specified in the plan that would generally qualify for the
medical and dental expenses deduction, which is explained in IRS Publication 502. The plan is
usually funded by the employee with pretax dollars. In some instances, an employer might
contribute small amounts. This is a "use it or lose it" type plan.
gatekeeper correct answers one who regulates access to someone or something; in insurance, a
primary care physician who coordinates the patient's referral to specialists and hospital
admissions.
geographic practice cost index (GPCI) correct answers each of the RSRVS components is then
adjusted for geographical cost differences by multiplying each by a geographic practice cost
index. This results in different payment amounts, depending on the location of the provider's
practice, and amounts can vary from state to state and even within the same state, depending on
whether the location is considered urban or suburban.
, health maintenance organizations correct answers a type of managed care operation that is
typically set up as a for-profit corporation with salaried employees; group insurance that entitles
members to services provided by participating hospitals, clinics, and providers.
Health Reimbursement Arrangement (HRA) correct answers pays for medical expenses. It can be
paired with a standard or high-deductible health plan. An employer can contribute to an HRA,
but an employee cannot.
Health Savings Account (HSA) correct answers a tax-sheltered savings account, with
contributions from the employer and employee, which can be used to pay for medical expenses.
indemnity type insurance correct answers a type of insurance plan that has the least amount of
structural guidelines for patients to follow. Patients are able to see the provider of their choice
without having to deal with listings of participating providers and other managed care guidelines.
independent practice associations (IPA) correct answers an association of independent
physicians, or other organization that contracts with independent physicians, and provides
services to managed care organizations on a negotiated per capita rate, flat retainer fee, or
negotiated fee-for-service basis; also known as individual practice associations, they consist of
providers who practice in their own individual offices and retain their own office staff and
operations; a type of HMO in which contracted services are provided by providers who maintain
their own offices.
medicare correct answers a federal program for providing health care coverage for individuals
over the age of 65 or those who are disabled.
medicare advantage correct answers the Part C segment of Medicare that enables beneficiaries to
select a managed care plan as their primary coverage.
medicaid correct answers a joint funding program by federal and state governments (excluding
Arizona) for the medical care of low-income patients on public assistance.
accept assignment correct answers participating physician's agreement to accept allowed charge
as full payment
Advance Beneficiary Notice (ABN) correct answers document used to notify a Medicare
beneficiary that it is either unlikely that Medicare will pay or certain that Medicare will not pay
for the service they are going to be provided. Beneficiaries are required to sign this document if
they wish to have the service with the understanding that they will be responsible for payment.
Affordable Care Act correct answers An expansion of medicaid, most of employers must provide
health insurance, have insurance or face surtax, prevents rejection based on pre-existing
condition. Also referred to as "Obamacare", signed into law in 2010.
allowed amount correct answers the maximum amount an insurer will pay for any given service.
assignment of benefits correct answers the authorization, by signature of the patient, for payment
to be made directly by the patient's insurance to the provider for services.
beneficiary correct answers person entitled to benefits of an insurance policy. This term is most
widely used by Medicare.
birthday rule correct answers a means to identify primary responsibility in insurance coverage;
identifies the primary insurance carrier when children have coverage through more than one
parent. The insurance of the parent with the birthday earliest in the year, month and day only, is
identified as the primary insurer. If both parents have the same birth date, the policy that has
been in effect the longest is the primary carrier.
capitation correct answers the health care provider is paid a fixed amount per member per month
for each patient who is a member of a particular insurance organization regardless of whether
services were provided.
,carrier correct answers A person whose genotype includes a gene that is not expressed in the
phenotype.
CMS-1500 correct answers the standard claim form designed by the Centers for Medicare and
Medicaid Services to submit physician services for third-party (insurance companies) payment;
the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper
claim is allowed.
coinsurance correct answers a percentage that a patient is responsible for paying for each service
after the deductible has been met.
conversion factor correct answers the dollar amount that converts the RVUs into a fee.
coordination of benefits correct answers when both spouses have health care insurance, the
policy provision that limits benefits to 100 percent of the cost; also known as dual coverage;
procedures insurers use to avoid duplication of payment on claims when the patient has more
than one policy. One insurer becomes the primary payer, and no more than 100 percent of the
costs are covered.
co-payment correct answers a specified amount the insured must pay toward the charge for
professional services rendered at the time of service.
deductible correct answers an amount to be paid before insurance will pay.
dependent correct answers person covered under a subscriber's insurance policy; refers to
spouses and dependent children.
Diagnosis-related groups (DRGs) correct answers method of determining reimbursement from
medical insurance according to diagnosis on a prospective basis.
,Exclusive Provider Organization (EPO) correct answers EPOs are like HMOs in that patients
must use their EPO's provider network when receiving care. There is no partial coverage for out-
of-network care.
explanation of benefits correct answers a printed description of the benefits provided by the
insurer to the beneficiary; provides information to the patient about how an insurance claim from
a health provider (such as a physician or hospital) was paid on their behalf.
fee-for-service correct answers payment for each service that is provided; individuals who
choose to pay high premiums so that they have the flexibility to seek medical care from health
care professionals of their choice.
fee schedule correct answers a list of predetermined payment amounts for professional services
provided to patients.
flexible spending arrangement (FSA) correct answers pretax funds set aside for use in payment
of medical services and supplies not covered by insurance; referred to as a cafeteria plan.
Qualified medical expenses are those specified in the plan that would generally qualify for the
medical and dental expenses deduction, which is explained in IRS Publication 502. The plan is
usually funded by the employee with pretax dollars. In some instances, an employer might
contribute small amounts. This is a "use it or lose it" type plan.
gatekeeper correct answers one who regulates access to someone or something; in insurance, a
primary care physician who coordinates the patient's referral to specialists and hospital
admissions.
geographic practice cost index (GPCI) correct answers each of the RSRVS components is then
adjusted for geographical cost differences by multiplying each by a geographic practice cost
index. This results in different payment amounts, depending on the location of the provider's
practice, and amounts can vary from state to state and even within the same state, depending on
whether the location is considered urban or suburban.
, health maintenance organizations correct answers a type of managed care operation that is
typically set up as a for-profit corporation with salaried employees; group insurance that entitles
members to services provided by participating hospitals, clinics, and providers.
Health Reimbursement Arrangement (HRA) correct answers pays for medical expenses. It can be
paired with a standard or high-deductible health plan. An employer can contribute to an HRA,
but an employee cannot.
Health Savings Account (HSA) correct answers a tax-sheltered savings account, with
contributions from the employer and employee, which can be used to pay for medical expenses.
indemnity type insurance correct answers a type of insurance plan that has the least amount of
structural guidelines for patients to follow. Patients are able to see the provider of their choice
without having to deal with listings of participating providers and other managed care guidelines.
independent practice associations (IPA) correct answers an association of independent
physicians, or other organization that contracts with independent physicians, and provides
services to managed care organizations on a negotiated per capita rate, flat retainer fee, or
negotiated fee-for-service basis; also known as individual practice associations, they consist of
providers who practice in their own individual offices and retain their own office staff and
operations; a type of HMO in which contracted services are provided by providers who maintain
their own offices.
medicare correct answers a federal program for providing health care coverage for individuals
over the age of 65 or those who are disabled.
medicare advantage correct answers the Part C segment of Medicare that enables beneficiaries to
select a managed care plan as their primary coverage.
medicaid correct answers a joint funding program by federal and state governments (excluding
Arizona) for the medical care of low-income patients on public assistance.
