Medical Billing And Coding Test Questions And Answers
Rated A
Medical Insurance - -Financial plan (the
payer) that covers the cost of hospital and
medical care Disability Insurance - -Replaces income
lost because the insured cannot work
Policyholder - -Person who buys an
insurance plan; the insured, subscriber, or Workers' Compensation Insurance - -
guarantor Provides benefits for an insured injured on the
job
Health Plan - -Individual or group plan that
provides or pays for the cost of medical care Indemnity Insurance - -Payment method is
fee-for-service based on the contract's schedule
of benefits,fee is paid AFTER the patient receives
Benefits - -What a health plan pays for services from the physician.
services covered in an insurance policy; listed in
the schedule of benefits.
Managed care - -A system that combines
the financing and the delivery of appropriate,
Medical Necessity - -Reasonable services cost-effective health care services to its
of provider (doctor or facility) consistent with members.
professional medical standards.
Premium - -Periodic payment the patient is
Covered Services - -Determined as being required to make to keep the policy in effect.
medically necessary and both reasonable and
consistent with the standards for the diagnosis or
treatment of injury or illness. Deductible - -Amount that the insured pays
on covered services before benefits begin.
Non-covered Services - -Medical
procedures not covered in a plans benefits. Coinsurance - -Percentage of each claim
that the insured pays; states the health plan's
percentage of the charge, followed by the
Individual Health Plan (I H P) - -contract insured's percentage.
between individual and the plan
known as direct pay.
Health Maintenance Organizations (HMOs) -
-A manged health care system in which
Group Health Plan (G H P) - -contract providers agree to offer healthcare to the
between an employer or organization and the organization's members for fixed periodic
plan, payments from the plan.
the group members are insured as "subscribers".
, Medical Billing And Coding Test Questions And Answers
Rated A
Idea that patients who pay for health care
capitation Method - -a fixed prepayment services become more careful consumers.
made to the medical provider for all necessary
contracted services provided to each patient who
is a plan member no matter how much medical Private Payers - -Have contracts with
care is received during the determined time businesses to provide benefits for their
period. employees...better rates
Per member per month, (PMPM) - -(per self-funded health plans - -The
member per month): The "capitated rate" organization "insures itself"
Capitation this amount is paid to the health care a company creates its own insurance plan for its
provider based on the schedule of benefits, no employees, rather than using a carrier; the plan
matter how much medical care is received during assumes payment risk, contracts with physicians,
the determined time period. and pays for claims from its funds.
Point of Service Plan (PPO) - -Combines Medicare - -Coverage for those age 65 and
features of both HMOs and PPOs Also called an older, people with certain disabilities, and people
"open access HMO "Allows members to see with permanent kidney failure.
providers in or out of HMO's network Members
pay more for out-of-network providers.
Medicaid - -Coverage for low-income
people who cannot afford medical care
Preferred Provider Organizations (PPO) - -
A managed care organization structured as a
network of health care providers who agree to TRICARE - -(was CHAMPUS): Coverage
perform services for plan members at discounted for active-duty military personnel, their spouses,
fees; usually, plan members can receive services children, and other dependents; also retired
from non-network providers for a higher charge. military personnel and their dependents, as well
PPOs control the cost of health care by: as family members of deceased active-duty
Directing patients' choices of providers personnel
Controlling use of services
Requiring preauthorization for services
Requiring Cost-sharing CHAMPVA - -Coverage for veterans with
permanent service-related disabilities and their
dependents.
Consumer-Driven Health
Plans (CDHP) - -Combine two elements:
A health plan, usually a PPO, that has a high Payer Adjudication - -Payers review claims
deductible (such as $1,000) and low premiums by following the adjudication process
A special "savings account" that is used to pay Puts the claim through a series of steps designed
medical bills before the deductible has been met to judge whether it should be paid or not
Cost containment plan based on consumerism: The payer's decision is explained on a report sent
Rated A
Medical Insurance - -Financial plan (the
payer) that covers the cost of hospital and
medical care Disability Insurance - -Replaces income
lost because the insured cannot work
Policyholder - -Person who buys an
insurance plan; the insured, subscriber, or Workers' Compensation Insurance - -
guarantor Provides benefits for an insured injured on the
job
Health Plan - -Individual or group plan that
provides or pays for the cost of medical care Indemnity Insurance - -Payment method is
fee-for-service based on the contract's schedule
of benefits,fee is paid AFTER the patient receives
Benefits - -What a health plan pays for services from the physician.
services covered in an insurance policy; listed in
the schedule of benefits.
Managed care - -A system that combines
the financing and the delivery of appropriate,
Medical Necessity - -Reasonable services cost-effective health care services to its
of provider (doctor or facility) consistent with members.
professional medical standards.
Premium - -Periodic payment the patient is
Covered Services - -Determined as being required to make to keep the policy in effect.
medically necessary and both reasonable and
consistent with the standards for the diagnosis or
treatment of injury or illness. Deductible - -Amount that the insured pays
on covered services before benefits begin.
Non-covered Services - -Medical
procedures not covered in a plans benefits. Coinsurance - -Percentage of each claim
that the insured pays; states the health plan's
percentage of the charge, followed by the
Individual Health Plan (I H P) - -contract insured's percentage.
between individual and the plan
known as direct pay.
Health Maintenance Organizations (HMOs) -
-A manged health care system in which
Group Health Plan (G H P) - -contract providers agree to offer healthcare to the
between an employer or organization and the organization's members for fixed periodic
plan, payments from the plan.
the group members are insured as "subscribers".
, Medical Billing And Coding Test Questions And Answers
Rated A
Idea that patients who pay for health care
capitation Method - -a fixed prepayment services become more careful consumers.
made to the medical provider for all necessary
contracted services provided to each patient who
is a plan member no matter how much medical Private Payers - -Have contracts with
care is received during the determined time businesses to provide benefits for their
period. employees...better rates
Per member per month, (PMPM) - -(per self-funded health plans - -The
member per month): The "capitated rate" organization "insures itself"
Capitation this amount is paid to the health care a company creates its own insurance plan for its
provider based on the schedule of benefits, no employees, rather than using a carrier; the plan
matter how much medical care is received during assumes payment risk, contracts with physicians,
the determined time period. and pays for claims from its funds.
Point of Service Plan (PPO) - -Combines Medicare - -Coverage for those age 65 and
features of both HMOs and PPOs Also called an older, people with certain disabilities, and people
"open access HMO "Allows members to see with permanent kidney failure.
providers in or out of HMO's network Members
pay more for out-of-network providers.
Medicaid - -Coverage for low-income
people who cannot afford medical care
Preferred Provider Organizations (PPO) - -
A managed care organization structured as a
network of health care providers who agree to TRICARE - -(was CHAMPUS): Coverage
perform services for plan members at discounted for active-duty military personnel, their spouses,
fees; usually, plan members can receive services children, and other dependents; also retired
from non-network providers for a higher charge. military personnel and their dependents, as well
PPOs control the cost of health care by: as family members of deceased active-duty
Directing patients' choices of providers personnel
Controlling use of services
Requiring preauthorization for services
Requiring Cost-sharing CHAMPVA - -Coverage for veterans with
permanent service-related disabilities and their
dependents.
Consumer-Driven Health
Plans (CDHP) - -Combine two elements:
A health plan, usually a PPO, that has a high Payer Adjudication - -Payers review claims
deductible (such as $1,000) and low premiums by following the adjudication process
A special "savings account" that is used to pay Puts the claim through a series of steps designed
medical bills before the deductible has been met to judge whether it should be paid or not
Cost containment plan based on consumerism: The payer's decision is explained on a report sent
