ESTUDYR
CHFP MODULE 1 CERTIFICATION UPDATED EXAM WITH MOST TESTED
QUESTIONS AND ANSWERS | GRADED A+ | ASSURED SUCCESS WITH
DETAILED RATIONALES
Question 1: A pre-determined amount that the patient must pay before the insurer begins to cover
services is called the:
a. Deductible
b. Copayment
c. Coinsurance
d. Premium
e. Out-of-pocket maximum
Rationale: The deductible is the dollar figure the patient owes upfront each year before insurance
payments commence.
1. Question 2: A percentage of the insurer’s allowed amount that the patient pays after meeting
the deductible is known as:
a. Copayment
b. Coinsurance
c. Balance billing
d. Premium surcharge
e. Co-premium
Rationale: Coinsurance represents the patient’s share (e.g., 20%) of the allowed charge once the
deductible is satisfied.
2. Question 3: A fixed dollar amount paid by the patient at each doctor’s office visit or prescription
fill is called a:
a. Deductible
b. Coinsurance
c. Copayment
d. Co-premium
e. Balance transfer
Rationale: A copayment is a flat fee (e.g., $20) due at the time of service, regardless of total charges.
3. Question 4: Payments made by patients for services not covered by their benefit plan, plus any
balance billed by out-of-network providers, are considered:
a. Co-insurance only
b. Out-of-pocket payment
c. Premium payments
d. Allowed amounts
e. Provider write-offs
,ESTUDYR
Rationale: Out-of-pocket payment includes copays, coinsurance, noncovered services, and any amounts
providers bill beyond the insurer’s payment.
4. Question 5: The total amount a patient is responsible for (including deductible, copays,
coinsurance, noncovered services, and balance billing) is defined as:
a. Patient premium
b. Provider reimbursement
c. Cost (to the patient)
d. Allowed amount
e. Charge
Rationale: “Cost (to the patient)” aggregates all direct payments by the patient, separate from insurance
premiums.
5. Question 6: All expenses—both direct (e.g., supplies) and indirect (e.g., facility overhead)—
incurred to deliver care are referred to as:
a. Charges
b. Costs (to the provider)
c. Capital expenditures
d. Balance sheet liabilities
e. Copayments
Rationale: Provider costs encapsulate every resource used in patient care, from staffing to equipment
depreciation.
6. Question 7: The amount an insurer reimburses a provider (or to be reimbursed to the patient if
they prepaid) for covered services rendered is termed:
a. Cost (to the health plan/insurer)
b. Allowed amount
c. Charge master rate
d. Copayment
e. Premium
Rationale: “Cost (to the health plan)” refers to the insurer’s expenditure on claims for covered services.
7. Question 8: Expenditures by an employer for employee health benefits—whether premiums or
employer-paid claims—are described as:
a. Premium sharing
b. Administrative fees
c. Cost (to the employer)
d. Co-premiums
e. Benefit offsets
,ESTUDYR
Rationale: “Cost (to the employer)” includes the employer’s portion of premiums and any self-funded
claim expenses.
8. Question 9: The initial price a provider sets for a service before any negotiated discounts or
adjustments is known as the:
a. Allowed amount
b. Charge
c. Copayment
d. Coinsurance
e. Deductible
Rationale: The “charge” (listed charge or charge master price) is the provider’s published rate prior to
insurer or negotiated write-downs.
9. Question 10: The total monetary value a provider expects to receive, combining insurer
payments and patient payments for all services, is defined as:
a. Charge
b. Allowed amount
c. Price
d. Premium
e. Balance billing
Rationale: “Price” describes the sum of charges minus write-offs, representing expected reimbursement
from payers and patients.
10. Question 11: An organization that negotiates provider rates, collects premiums, processes
claims, and pays providers is called a:
a. Pharmacy Benefit Manager (PBM)
b. Health Plan/Payer
c. Independent Practice Association (IPA)
d. Third-Party Administrator (TPA)
e. Utilization Review Firm
Rationale: Health plans/payers (e.g., Blue Cross, Aetna) administer benefits, contract with providers,
and handle billing and reimbursements.
11. Question 12: The recurring periodic fee patients pay for coverage, separate from any utilization-
based cost-sharing, is called the:
a. Deductible
b. Coinsurance
c. Premium
d. Copayment
e. Co-insurance
, ESTUDYR
Rationale: A premium is paid monthly (or quarterly) to maintain insurance coverage, independent of
actual healthcare usage.
12. Question 13: When a provider bills a patient for the difference between their billed charge and
the insurer’s allowed amount, the process is called:
a. Adjudication
b. Premium sharing
c. Balance billing
d. Cost shifting
e. Write-off
Rationale: Balance billing occurs when patients are billed for amounts not paid by the insurer—typically
with out-of-network providers.
13. Question 14: The maximum amount a patient must pay out-of-pocket in a calendar year, after
which the insurer pays 100% of covered services, is known as the:
a. Deductible
b. Coinsurance
c. Out-of-pocket maximum
d. Premium
e. Copayment
Rationale: Once a patient’s cumulative deductibles, copays, and coinsurance reach the out-of-pocket
max, the insurer covers subsequent covered expenses in full.
14. Question 15: If a family plan requires each adult to satisfy a separate $1,500 deductible, but the
family deductible caps out at $3,000 total, the family deductible is an example of a(n):
a. Individual deductible
b. Family deductible
c. Embedded deductible
d. Integrated deductible
e. Aggregate deductible
Rationale: A family deductible sets a cap on combined contributions of all members; individuals may
have separate obligations until the family limit is met.
15. Question 16: The highest allowed charge a plan will reimburse for a service, beyond which the
patient becomes responsible, is called the:
a. Premium rate
b. Charge master rate
c. Allowed amount
d. Balance bill
e. Reference-based price
CHFP MODULE 1 CERTIFICATION UPDATED EXAM WITH MOST TESTED
QUESTIONS AND ANSWERS | GRADED A+ | ASSURED SUCCESS WITH
DETAILED RATIONALES
Question 1: A pre-determined amount that the patient must pay before the insurer begins to cover
services is called the:
a. Deductible
b. Copayment
c. Coinsurance
d. Premium
e. Out-of-pocket maximum
Rationale: The deductible is the dollar figure the patient owes upfront each year before insurance
payments commence.
1. Question 2: A percentage of the insurer’s allowed amount that the patient pays after meeting
the deductible is known as:
a. Copayment
b. Coinsurance
c. Balance billing
d. Premium surcharge
e. Co-premium
Rationale: Coinsurance represents the patient’s share (e.g., 20%) of the allowed charge once the
deductible is satisfied.
2. Question 3: A fixed dollar amount paid by the patient at each doctor’s office visit or prescription
fill is called a:
a. Deductible
b. Coinsurance
c. Copayment
d. Co-premium
e. Balance transfer
Rationale: A copayment is a flat fee (e.g., $20) due at the time of service, regardless of total charges.
3. Question 4: Payments made by patients for services not covered by their benefit plan, plus any
balance billed by out-of-network providers, are considered:
a. Co-insurance only
b. Out-of-pocket payment
c. Premium payments
d. Allowed amounts
e. Provider write-offs
,ESTUDYR
Rationale: Out-of-pocket payment includes copays, coinsurance, noncovered services, and any amounts
providers bill beyond the insurer’s payment.
4. Question 5: The total amount a patient is responsible for (including deductible, copays,
coinsurance, noncovered services, and balance billing) is defined as:
a. Patient premium
b. Provider reimbursement
c. Cost (to the patient)
d. Allowed amount
e. Charge
Rationale: “Cost (to the patient)” aggregates all direct payments by the patient, separate from insurance
premiums.
5. Question 6: All expenses—both direct (e.g., supplies) and indirect (e.g., facility overhead)—
incurred to deliver care are referred to as:
a. Charges
b. Costs (to the provider)
c. Capital expenditures
d. Balance sheet liabilities
e. Copayments
Rationale: Provider costs encapsulate every resource used in patient care, from staffing to equipment
depreciation.
6. Question 7: The amount an insurer reimburses a provider (or to be reimbursed to the patient if
they prepaid) for covered services rendered is termed:
a. Cost (to the health plan/insurer)
b. Allowed amount
c. Charge master rate
d. Copayment
e. Premium
Rationale: “Cost (to the health plan)” refers to the insurer’s expenditure on claims for covered services.
7. Question 8: Expenditures by an employer for employee health benefits—whether premiums or
employer-paid claims—are described as:
a. Premium sharing
b. Administrative fees
c. Cost (to the employer)
d. Co-premiums
e. Benefit offsets
,ESTUDYR
Rationale: “Cost (to the employer)” includes the employer’s portion of premiums and any self-funded
claim expenses.
8. Question 9: The initial price a provider sets for a service before any negotiated discounts or
adjustments is known as the:
a. Allowed amount
b. Charge
c. Copayment
d. Coinsurance
e. Deductible
Rationale: The “charge” (listed charge or charge master price) is the provider’s published rate prior to
insurer or negotiated write-downs.
9. Question 10: The total monetary value a provider expects to receive, combining insurer
payments and patient payments for all services, is defined as:
a. Charge
b. Allowed amount
c. Price
d. Premium
e. Balance billing
Rationale: “Price” describes the sum of charges minus write-offs, representing expected reimbursement
from payers and patients.
10. Question 11: An organization that negotiates provider rates, collects premiums, processes
claims, and pays providers is called a:
a. Pharmacy Benefit Manager (PBM)
b. Health Plan/Payer
c. Independent Practice Association (IPA)
d. Third-Party Administrator (TPA)
e. Utilization Review Firm
Rationale: Health plans/payers (e.g., Blue Cross, Aetna) administer benefits, contract with providers,
and handle billing and reimbursements.
11. Question 12: The recurring periodic fee patients pay for coverage, separate from any utilization-
based cost-sharing, is called the:
a. Deductible
b. Coinsurance
c. Premium
d. Copayment
e. Co-insurance
, ESTUDYR
Rationale: A premium is paid monthly (or quarterly) to maintain insurance coverage, independent of
actual healthcare usage.
12. Question 13: When a provider bills a patient for the difference between their billed charge and
the insurer’s allowed amount, the process is called:
a. Adjudication
b. Premium sharing
c. Balance billing
d. Cost shifting
e. Write-off
Rationale: Balance billing occurs when patients are billed for amounts not paid by the insurer—typically
with out-of-network providers.
13. Question 14: The maximum amount a patient must pay out-of-pocket in a calendar year, after
which the insurer pays 100% of covered services, is known as the:
a. Deductible
b. Coinsurance
c. Out-of-pocket maximum
d. Premium
e. Copayment
Rationale: Once a patient’s cumulative deductibles, copays, and coinsurance reach the out-of-pocket
max, the insurer covers subsequent covered expenses in full.
14. Question 15: If a family plan requires each adult to satisfy a separate $1,500 deductible, but the
family deductible caps out at $3,000 total, the family deductible is an example of a(n):
a. Individual deductible
b. Family deductible
c. Embedded deductible
d. Integrated deductible
e. Aggregate deductible
Rationale: A family deductible sets a cap on combined contributions of all members; individuals may
have separate obligations until the family limit is met.
15. Question 16: The highest allowed charge a plan will reimburse for a service, beyond which the
patient becomes responsible, is called the:
a. Premium rate
b. Charge master rate
c. Allowed amount
d. Balance bill
e. Reference-based price
