Reimbursement Exam 1 with Complete
Solutions
Premium - correct Answer-The amount if money that must be periodically paid to a
health insurance company in return for healthcare coverage (both employer and
employee pay)
Risk pool - correct Answer-Group of individuals or entities who have similar risk of loss
Deductible - correct Answer-The amount of money you pay out of pocket before your
insurance starts to pay
Coordination of benefits - correct Answer-Determines which insurance pays first if
patients has more than on plan
Benefits - correct Answer-Healthcare services for which the insurance company will pay
as outlined in the policy
Cost sharing provisions - correct Answer-Out-of-pocket expenses that the insured must
pay
Copayment - correct Answer-A fixed amount you pay each time you get a specific type
of healthcare service
Coinsurance - correct Answer-A percentage of the cost you pay after you've met your
deductible
Tiered Benefits - correct Answer-A system where your insurance plan puts providers
(doctors, hospitals, drugs) into tiers, and your costs depend on the tier
Prior approval - correct Answer-Certain service require prior approval in order for the
service to be covered. Failure to obtain prior approval will result in the service being
denied
Other party liability - correct Answer-Utilized when multiple insurers, health and
nonhealthy, are involved. Ensure that health insurance is not paying for services that
are the responsibility of nonhealth insurance
Network restrictions - correct Answer-Patients pay less for in network providers, higher
cost for out of network
, Preauthorization requirements - correct Answer-Prevents unnecessary tests or
procedures
Utilization review - correct Answer-Evaluates medical necessity of services before,
during, or after care
Case Management - correct Answer-Coordinates care for high-need patients to avoid
duplication and reduce costs
Capitation - correct Answer-Providers receive a fixed payment per patient, regardless of
how many services are used
Gatekeeping - correct Answer-Patients must go through a primary care doctor for
referrals to specialists
Drug Formularies - correct Answer-Tiered medication lists to encourage use of lower-
cost, generic drugs
Disease Management Programs - correct Answer-Target chronic conditions (like
diabetes, asthma) to prevent costly complications
PACE - correct Answer-A Medicare and Medicaid program that helps eligible seniors
receive comprehensive healthcare and social services in their community instead of a
nursing home
CHAMPVA - correct Answer-Covers surviving spouses and dependent children of
veterans who died as a result of service-related disabilities
Medicare part A - correct Answer-Hospital insurance that helps cover costs for inpatient
hospital stays, care in a skilled nursing facility (after a hospital stay), hospice care, and
some home health care
Medicare part B - correct Answer-The part of the Medicare program that pays for
physician services, outpatient hospital services, durable medical equipment, and other
services and supplies.
Medicare part C - correct Answer-Medicare Part C, also known as a Medicare
Advantage plan, is a type of Medicare-approved health plan offered by private
companies that provide an alternative to Original Medicare
Medicare part D - correct Answer-Optional prescription drug coverage, provided by
private insurance companies, that helps Medicare beneficiaries pay for self-
administered prescription drugs
Solutions
Premium - correct Answer-The amount if money that must be periodically paid to a
health insurance company in return for healthcare coverage (both employer and
employee pay)
Risk pool - correct Answer-Group of individuals or entities who have similar risk of loss
Deductible - correct Answer-The amount of money you pay out of pocket before your
insurance starts to pay
Coordination of benefits - correct Answer-Determines which insurance pays first if
patients has more than on plan
Benefits - correct Answer-Healthcare services for which the insurance company will pay
as outlined in the policy
Cost sharing provisions - correct Answer-Out-of-pocket expenses that the insured must
pay
Copayment - correct Answer-A fixed amount you pay each time you get a specific type
of healthcare service
Coinsurance - correct Answer-A percentage of the cost you pay after you've met your
deductible
Tiered Benefits - correct Answer-A system where your insurance plan puts providers
(doctors, hospitals, drugs) into tiers, and your costs depend on the tier
Prior approval - correct Answer-Certain service require prior approval in order for the
service to be covered. Failure to obtain prior approval will result in the service being
denied
Other party liability - correct Answer-Utilized when multiple insurers, health and
nonhealthy, are involved. Ensure that health insurance is not paying for services that
are the responsibility of nonhealth insurance
Network restrictions - correct Answer-Patients pay less for in network providers, higher
cost for out of network
, Preauthorization requirements - correct Answer-Prevents unnecessary tests or
procedures
Utilization review - correct Answer-Evaluates medical necessity of services before,
during, or after care
Case Management - correct Answer-Coordinates care for high-need patients to avoid
duplication and reduce costs
Capitation - correct Answer-Providers receive a fixed payment per patient, regardless of
how many services are used
Gatekeeping - correct Answer-Patients must go through a primary care doctor for
referrals to specialists
Drug Formularies - correct Answer-Tiered medication lists to encourage use of lower-
cost, generic drugs
Disease Management Programs - correct Answer-Target chronic conditions (like
diabetes, asthma) to prevent costly complications
PACE - correct Answer-A Medicare and Medicaid program that helps eligible seniors
receive comprehensive healthcare and social services in their community instead of a
nursing home
CHAMPVA - correct Answer-Covers surviving spouses and dependent children of
veterans who died as a result of service-related disabilities
Medicare part A - correct Answer-Hospital insurance that helps cover costs for inpatient
hospital stays, care in a skilled nursing facility (after a hospital stay), hospice care, and
some home health care
Medicare part B - correct Answer-The part of the Medicare program that pays for
physician services, outpatient hospital services, durable medical equipment, and other
services and supplies.
Medicare part C - correct Answer-Medicare Part C, also known as a Medicare
Advantage plan, is a type of Medicare-approved health plan offered by private
companies that provide an alternative to Original Medicare
Medicare part D - correct Answer-Optional prescription drug coverage, provided by
private insurance companies, that helps Medicare beneficiaries pay for self-
administered prescription drugs
