Insurance Essentials Exam 1

Front 1

Of the federal programs providing healthcare, the largest is what, which provides health insurance for citizens age 65 and older?

Back 1

Medicare

Front 2

What is the authorization called that directs and insurance carrier to pay the medical provider or the medical practice directly?

Back 2

Assignment of benefits

Front 3

Patients who belong to a managed-care health plan such as an HMO are responsible for a small per visit fee collected at the time of the visit this fee is commonly called a what?

Back 3

Copayment

Front 4

The fixed dollar amount a subscriber must pay or meet each year before the insurer begins to cover expenses is the what?

Back 4

Deductible

Front 5

The person whose name the insurance is carried under is called the what?

Back 5

Subscriber

Front 6

When the insured person pays an annual cost for healthcare insurance it is called a what?

Back 6

Premium

Front 7

The most likely outcome of an insurance claim submitted with a diagnosis code of a sore throat and a treatment code indicating a cast for a broken leg would be what?

Back 7

Denied because the treatment was not medically necessary based on the diagnosis

Front 8

Which of the following is what the patient owes after the insurance company has paid?

Back 8

Patient liability

Front 9

And insurance claims department compares the fee the doctor charges with the benefits provided by the patient's health plan this is called the what?

Back 9

Review for allowable benefits

Front 10

Which insurance covers a patient who has been hospitalized up to 90 days for each benefit period?

Back 10

Medicare part A

Front 11

Which of the following is a characteristic of Medicaid?

Back 11

It is a health cost assistance program

Front 12

Which of the following statement applies to a physician who agrees to except Medicaid patients?

Back 12

The physician can bill a patient for services that Medicaid does not cover

Front 13

One advantage of submitting claims electronically is what?

Back 13

Electronic submissions are cost-efficient

Front 14

Which statement is true regarding health maintenance organization's?

Back 14

Physicians with HMO contracts are often paid a capitated rate

Front 15

A husband and wife are both employee and have work sponsor insurance plans that cover each other and their three children which insurance plan is the primary payer?

Back 15

The insurance plan of the person whose birthday comes first in the calendar year

Front 16

Which of the following is correct regarding electronic claims submissions?

Back 16

Claims are prepared for transmission after all require data elements have been entered

Front 17

Which of the following is correct regarding electronic claims submissions?

Back 17

Claims are prepared for transmission after all require data elements have been entered

Front 18

Which Medicare plan covers prescription medications?

Back 18

Part D

Front 19

What is the birthday rule?

Back 19

The insurance policy of the policyholder whose birthday comes first in the calendar year is the primary payer for all dependent

Front 20

What is the birthday rule?

Back 20

The insurance policy of the policyholder whose birthday comes first in the calendar year is the primary payer for all dependent

Front 21

The request for approval for payment from a third-party payer prior to a procedure is the what?

Back 21

Pre-authorization

Front 22

What is the birthday rule?

Back 22

The insurance policy of the policyholder whose birthday comes first in the calendar year is the primary payer for all dependent

Front 23

The request for approval for payment from a third-party payer prior to a procedure is the what?

Back 23

Pre-authorization

Front 24

The process of deciding the amount of money that will be paid by a third-party payer for a procedure is what?

Back 24

Predetermination

Front 25

Insurance carriers perform a review for medical_____on each claim to determine whether the treatment is needed for the diagnoses listed

Back 25

Necessity

Front 26

Insurance carriers perform a review for medical_____on each claim to determine whether the treatment is needed for the diagnoses listed

Back 26

Necessity

Front 27

An _____healthcare claim is one that is error-free and is excepted for processing by the payer

Back 27

Clean

Front 28

The payment system used by___is called the resource base relative value scale (RBRVS)

Back 28

Medicare

Front 29

Insurers include either an explanation of payment or a___device along with payment to the practice or to the patient depending on whether an assignment of benefits was signed

Back 29

Remittance

Front 30

Insurers include either an explanation of payment or a___device along with payment to the practice or to the patient depending on whether an assignment of benefits was signed

Back 30

Remittance

Front 31

A___procedure is a medical procedure that is not required to sustain life and that is planned in advance to be done at the convenience of The physician or surgeon and the patient

Back 31

Elective

Front 32

Because Medicare pays 80% of approved charges and the patient is responsible for the remaining 20% individuals enrolled in the original Medicare part B plan often buy additional insurance called a___plan

Back 32

Medigap

Front 33

Billing the patient for the difference between a higher usual fee and a lower allowed charge is called__billing

Back 33

Balance

Front 34

The provider should have the patient sign a___of benefits statement under which the provider agrees to prepare healthcare claims for the patient and to receive payments directly from the payer

Back 34

Assignment

Front 35

A fixed pre-payment is made under contract to a medical provider for each plan member and the___payment method

Back 35

Capitated

Front 36

The___is a fixed amount that must be paid by the policyholder each year before a third-party payer begins to cover medical expenses

Back 36

Deductible

Front 37

Payments made by a health plan for medical services provided to the patient or known as___

Back 37

Benefits

Front 38

Payments made by a health plan for medical services provided to the patient or known as___

Back 38

Benefits

Front 39

The___is the annual payment made to an insurance company by the patient to keep the insurance policy in effect

Back 39

Premium

Front 40

The___is a fixed percentage payable by the patient after that the deductible is met

Back 40

Coinsurance

Front 41

The___is a fixed percentage payable by the patient after that the deductible is met

Back 41

Coinsurance

Front 42

Expenses that are not covered by insurance plan are called___

Back 42

Exclusions

Front 43

A small fee that is collected at the time of service is called a___

Back 43

Co-pay