Administrative Procedures: Chapter 12

true

true or false coal in nearly all of the provider's income is derived from the insurance payments received for services rendered

true

true or false: Tricare is a form of government insurance for veterans of the US Armed Forces

true

true or false: a provider can choose whether to accept Medicaid patients

False

true or false: health insurance typically cover services and procedures considered medically necessary. Most insurance policies also cover elective procedures, such as certain cosmetic surgeries, that are not considered medically necessary

false

true or false: there are no government managed care plans

Part B

under which of the following Medicare plans for Primary Care and Specialists Services is the patient required to pay a monthly premium?

HMOs

which of the following MCOs typically has or have the lowest monthly premiums with lower patient financial responsibility?

all are correct

which of the following Services must be covered by Medicaid in each state?

fees for services provided

which of the following are not reviewed by a utilization Review Committee?

Physician's office visits

which of the following expenses would be paid by Medicare Part B?

authorized services are usually covered

which of the following is not a disadvantage of Managed Care?

access to Specialized Care and referrals is limited

which of the following is not an advantage of Managed Care?

all are correct

which of the following managed care plans require pre-authorization for medical services such as surgery?

all government-sponsored health plans and most privately sponsored health plans

which of the following plans require Healthcare Providers to become participating providers?

STAT referral

which of the following referrals can be approved online when it is submitted through the provider's web portal to the utilization review Department?

Part A

which part of Medicare covers inpatient Hospital charges?

D

which part of Medicare covers prescription drug services?

STAT

which type of referral is usually processed immediately?

TRICARE

health insurance designed for military dependents and retired military personnel

$3,087.20

if Mr Jones's insurance has a $500 deductible and then pays 80% of the charges, how much will his policy pay on his bill of $4,359?

Gatekeeper

in some managed care plans were ferral's to a specialist must be approved by the:

preventive care and procedures deemed medically necessary

most of today's health insurance policies cover which of the following?

self-funded plans

organizations that fund their own insurance programs offer their employees:

preventive

service provided to stop certain conditions from recurring or to lead to an early diagnosis are considered:

medically necessary

services that are needed to improve the patient's current health are considered

indigent

someone who is poor, needy, or impoverished is considered

all are correct

the Affordable Care Act includes which of the following categories of essential health benefits?

resource-based relative value scale

the allowed amount for Medicare charges is determined using

Premium

the amount of money paid to keep an insurance policy in force

deductible

the amount of money the policyholder pays per claim before the insurance company will pay on the claim is known as the

Medicaid

the federal and state sponsored health insurance program for the medically indigent is called

Health maintenance organizations

the health insurance mode that offers the least flexibility for patients is

traditional health insurance

the health insurance model that offers the most flexibility for patient is

all are correct

the medical assistant should always verify which of the following prior to the patient's appointment?

group policy

the policy that covers a number of people under a single contract issued to the employer

participating

the provider who enters into a contract with an insurance company and agrees to certain rules and regulations is called a ____ provider

TRICARE

dependents of military personnel are covered by which of the following government-sponsored health insurance plans?

the first statement is true; the second statement is false

employee group plans usually provide greater benefits at lower premiums because of the large pool of people from whom premiums are collected. However, these employee group health insurance plans offered limited benefits, and Health Care access is limited to healthcare providers that are contracted with them.

all are correct

RBRVS consists of three parts including which of the following?

TRICARE

Veterans of the US Armed Forces may be covered by

coinsurance

a certain percentage of the allowed amount that the policyholder is responsible for is

beneficiary

a designated person who receives funds from an insurance policy is

explanation of benefits

a document sent by the insurance company to the provider and the patient explaining the allowed charge, the amount reimbursed for services, and the patient's financial responsibilities is

claim

a formal request for payment from an insurance company for services provided

Fee schedules are based on which of the following?

a list of the fixed fees for services is a

capitation

a payment method in which providers are paid for each individual enrolled in a plan regardless of whether the person sees the provider that month, is called a ___ plan

pre-authorization

a process required by some insurance carriers in which the provider obtained permission to perform certain procedures or Services is

utilization review

a review of individual cases by a committee to make sure the services are medically necessary is called

copayment

a set dollar amount that the policyholder must pay for each office visit

workers compensation

a type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called

policy

a written agreement between two parties, where one party agrees to pay another party if certain specified circumstances occur is a

referral

an order from a primary care provider for the patient to see a specialist is

third party administrator

an organization that processes claims and provides administrative services for another organization is

provider Network

An approved list of Physicians hospitals and other providers is

all are correct

Medigap policies cover which of the following?