NCCT: Interactive Review: Medical Insurance
According to the patient's insurance plan, the copay for an office visit is $20. The copay for a specialist visit is $30. The patient had a carpal tunnel release done two weeks ago by an orthopedic surgeon. The patient has come into the orthopedic surgeon's office today for a follow up visit. Which of the following is the copay?
$0 There is no copay due at this time. This is because it is during the global surgical period of 90 days. During this time frame all services associated with the treatment is not billable.
The patient's EOB shows total charges $369.00, $6.00 patient liability, $363.00 is covered, $50.00 deductible, total paid to provider $250.40, and the policy is 80/20. Which of the following is the patient's total out of pocket cost? A. $62.60 B. $112.60 C. $118.60 D. $56.00
$118.60 For a non-participating provider, the cost of the service will be the total charge, which is $369. To find out how much the patient's total cost will be, subtract the total paid to provider from the total charges ($369 - $250.40 = $118.60).
Charges billed to the insurance company were for a total of $250.00. The allowed amount is $150.00 and the patient has a 90/10 plan. Which of the following is the co-insurance due from the patient?
$15.00 The allowable amount is the reduced cost of the service for seeing an in network provider. The new charge amount (the allowable) is $150. Since the patient is responsible for 10% of that charge, the patient is responsible for $15 (150 x .10 = 15).
The participating Medicare provider accepted assignment and will receive 80% of the allowed charges for today's visit, in the amount of $80. Which of the following amounts will be the beneficiary's responsibility?
$20.00 After the Medicare deductible has been satisfied, Medicare will pay the provider 80% of the allowable and the beneficiary will be responsible for 20% of the allowable. If Medicare paid $80.00, then the allowed amount is $100.00 (100 x 80% = 80.00). $2.00 is incorrect because $2.00 is 2% and not the required 20%. $20.00 is the required 20% of the $100.00 so it is the correct answer. $8.00 is incorrect because $8.00 is 8% and not the required 20%. $16.00 is 16% and not the required 20%. It is important to know that Medicare pays at 80% and the beneficiary pays 20% after the deductible has been satisfied.
A patient was billed for $900.00 with a policy of 75/25 when in network and 60/40 out of network. The patient was treated by a PAR physician. Which of the following is the coinsurance amount?
$225.00 a PAR physician is an in network provider and would be paid at the 75/25 level. It would be figured as follows: Reimbursement from the insurance carrier will be 75% of the $900.00 charges, this amount is $675.00. The patient portion responsibility is the 25% calculation of $225.00. Had the patient seen a NON-PAR physician at the 60/40 level it would have been processed as follows: 60% reimbursement from the insurance carrier of $540.00 and the 40% patient responsibility would be $360.00
Charges are $155.00 and the allowed amount is $120.00. How much should the insurance and coding specialist collect from a patient who has Medicare?
$24.00 the patient responsibility for their service is always 20% of the allowed amount. $120.00 x 20% = $24.00. This will be the patient responsibility.
A patient had recently been to her cardiologist. She tries to figure her total responsibility. On the Explanation of Benefits the patient sees that her BCBS pays 80%. The following information was provided: $1,070.00 amount billed $620.00 allowable amount $350.00 applied to annual deductible $20.00 copayment Which of the following amounts is the patient's total responsibility?
$474.00 In order to calculate the patient's total responsibility, one must first determine whether the physician is participating or non-participating. In this scenario, the cardiologist is a participating provider, which means that we will start with the allowable amount since this is the discounted rate for seeing a participating provider. We will take that $620 and multiply it by the patient's portion of the charge, which is 20% ($620 x 0.20= $124). Next, since the patient has not yet paid her deductible, that $350 will get added to the patient's total responsibility for a total of $474 ($124 + $350 = $474.)
A patient was seen by a specialist today in the clinic. The allowable charge for services today is $700.00. The policy is 80/20. The deductible is $1000.00, of which $500.00 has been met. Which of the following amounts is the patient's total out of pocket for the services? A. $360.00 B. $500.00 C. $140.00 D. $540.00
$500.00 Rationale Typically, in an 80/20 policy, the insurance will pay 80% and the patient will pay 20% of an allowable charge. 80% of $700 is $560 and 20% of $700 is $140. However, since the patient still has a $500 deductible to meet, the insurance company will not make any payments until that $500 deductible has been met. In this case the calculation starts with the patient's 20% of the charge and subtract it from the $500 deductible, which leaves $360 still to be met for the deductible. That $360 needs to be added to the patient's responsibility, making the patient's total responsibility $500 ($140 + $360).
Level 2 visit for a cold: $95 contract rate (80% paid from Insurance / 20% due from patient after deductible met) $200 deductible with $49 met to date. Which of the following is the amount owed by the patient? A. $18 B. $46 C. $95 D. $151
$95 This policy pays at 80/20 after the deductible has been met by the patient. At this point the patient has only met $49.00 of the required $200.00 deductible. This leaves a balance of $151.00 of the required deductible to be met. The charges are $95.00 and this would go toward the deductible balance and be the patient's responsibility to pay.
Which of the following is the maximum amount of time allowed to file a claim through Medicare?
12 months from the date of service Per CMS.gov, on or after January 1, 2010, the time limit for filing all Medicare Fee-For- Service claims (Part A and Part B claims) is 12 months, or one calendar year from the date services were furnished.
Place the options below in order of claim submission, where all insurances are relevant. (Click and drag the options in the left column to their correct position in the right column.): Medicare, Medicaid, Humana, ABC Auto
ABC Auto, Humana, Medicare, Medicaid: It is highly unlikely that a patient would have all four of these insurances. However, if they do, the order in which the claims are submitted is relevant. It is assumed that since there is auto insurance involved, that this claim has to do with an automobile accident. The auto insurance should be filed first. Humana, a private payer, should be filed next. Government insurance, such as Medicare and Medicaid, should always be submitted last. When both Medicare and Medicaid are valid, Medicaid should be billed last.
The patient had United Health Care HMO group insurance before she retired. Today she presented her Medicare Part B insurance card and her husband's Blue Cross Blue Shield PPO group insurance card to the insurance and coding specialist. Which of the following is the patient's primary insurance for today's visit?
Blue Cross Blue Shield PPO: Medicare Part B is not primary when the patient is part of a group sponsored health plan. United Health Care HMO is not in effect as the scenario indicates that the patient "had" the plan. Blue Cross Blue Shield PPO is primary to Medicare when the patient is part of a group sponsored health insurance plan and would be the correct response. Medicare Part A would not be correct because it is not mentioned in the scenario and is not used for office (outpatient) services.
When filing a claim in an outpatient setting, which of the following forms should be used?
CMS-1500 CMS-1500 is the claim form that must be submitted in an outpatient setting. A UB-40 form is used for hospital billing. A charge master is a list of common codes used in an office. An encounter form is used to help document a patient's visit. An encounter form and the charge master are used internally at the office and do not go to the insurance company.
Which of the following should the insurance and coding specialist check in order to determine which payer should be billed as primary or secondary?
COB: COB stands for Coordination of Benefits and determines the order in which the insurance specialist should bill the payers.
The patient scheduled his appointment with the name "Charles," but presented his insurance id card with the name "Charleston." Which of the following should the insurance and coding specialist use to complete the registration?
Charleston The name identified on the insurance card is the correct name to use. This is the name used for identification through the insurance company. If the correct name is not used, this will result in a denial because the patient's correct name has not been used.
A patient is referred to a specialist by the primary care provider. Pre-certification is required for this patient's specialty visit. Which of the following actions is required by the insurance and coding specialist to obtain authorization?
Contact the patient's insurance provider: An insurance and coding specialist must obtain an authorization for a patient to see the specialist. This authorization is obtained by contacting the patient's insurance provider for authorization before the patient can see the specialist
The patient asks the insurance and coding specialist to bill her secondary insurance first because the coverage is better. Which of the following should the specialist do? (Select the two (2) correct answers.)
Deny her request., Explain the guidelines and bill the primary insurance first. The patient's request to bill the secondary insurance first should be denied and the reason should be explained to the patient. Copays are not included for both the primary and secondary insurances. There is no need to involve the physician/provider.
Which of the following statements is true concerning a court order about children's health coverage after a divorce?
Divorce rulings override the birthday rule.
Which of the following insurance types requires a referral from a PCP in order to visit a specialist?
HMO An HMO (Health Maintenance Organization) plan will have lower monthly premiums but will require referrals from the primary care provider to see any other physician and also limits the patient to physicians in their network. A PPO (Preferred Provider Organization) plan usually costs more monthly, but gives the patient more freedom when choosing physicians. An EPO (Exclusive Provider Organization) plan requires a physician in the network. A POS (Point of Service) is similar to an HMO plan, since it requires PCP referrals, but allows the subscriber to see physicians out of network
Which of the following statements is true about preauthorization?
It only pertains to medical necessity and is not a guarantee of payment: Preauthorization only pertains to medical necessity and does not guarantee payment. It states that a treatment plan is plausible, due to the proper diagnosis, proper time frame, and other requirements for a service, depending on the medical necessity for that service. An example is an angiogram. According to medical necessity, if an angiogram is performed, a second angiogram may not be billed unless the patient's condition has changed or additional needed information indicated another angiogram is necessary. If the physician decides a second angiogram is medically necessary, she should submit for a preauthorization from the insurance company.
Which of the following statements should the insurance and coding specialist use to advise a patient that his annual deductible has not been met and he is responsible for the full cost of today's visit? "According to your insurance benefits, you owe $130... A. and there is no need to use your insurance for today's visit." B. This is just an estimate; your insurance carrier will reimburse you the difference." C. and you can reschedule the visit for next month." D. based on your benefit details."
based on your benefit details." It is always the best practice for an Insurance Specialist to refer to a patient's benefits when discussing any amount owed so "based on your benefits" is the correct response. "There is no need to use your insurance for today's visit" would not apply because the amount owed is based on the statement "according to your insurance benefits". Insurance carriers do not reimburse patients so "this is just an estimate; your insurance carrier will reimburse you the difference", would not be correct. "And you can reschedule the visit for next month" would apply if the patient had indicated that they are unable to pay for today's visit, but that information is not indicated in the scenario.
Which of the following physicians typically requires a referral with an HMO or POS policy?
cardiologist: The primary care provider can be seen without a referral. HMO and POS policies require referral from a physician when a patient's need to see a specialist (like a cardiologist, neurologist, orthopedic surgeon, etc.) is indicated. For instance, the primary care provider (PCP) would request that a patient presenting with a new heart issue see a cardiologist. Hence, the PCP would refer the patient to a cardiologist. Anesthesiologists and pathologists are physician specialists in their respective fields, but generally do not see patients in an office setting. These specialists support all medical personnel where services are provided. The primary realm of practice for pathologists is laboratory medicine whereas anesthesiologists are associated with surgical procedures.
Which of the following is the percentage the patient pays for covered service after the deductible has been met?
co-insurance Co-insurance is the amount the patient is responsible to pay for an allowable service, after the deductible has been met. Co-pay is to be paid before services are rendered. The premium is the payment for the actual insurance coverage. The allowed amount is the discounted rate that is charged for services rendered by a provider in the insurance company's network.
The patient has health insurance that covers 70% of her covered expenses that she has incurred which qualifies for reimbursement. The patient's responsibility will be 30%. This type of cost sharing is referred to as
coinsurance. Coinsurance is splitting the bill between multiple parties. These parties include the insurance company and the patient. Co-payments and deductibles are parts of the patient's coinsurance. Covered expenses are the insurance company's part of the coinsurance.
Billing practices that prevent the total payment received from multiple insurance companies from exceeding the patient's total bill are known as
coordination of benefits. Coordination of benefits is determining which insurance is primary, secondary, tertiary, etc., when the patient has multiple insurances. You may not bill all of the insurance companies at the same time. You must first bill the primary, wait for an EOB, adjust the patient records based on the EOB, then bill the secondary, and so on. If the billing and coding specialist were to bill all the insurance carriers at once, the total amount billed would be at least double the cost of the actual service. After receiving the EOB from the primary carrier, the billing and coding specialist may then bill the secondary, minus the amount the primary insurance has paid. Abuse prevention practices and fraud prevention practices make sure that this process is followed. Assignment of benefits is means the patient contracts that the benefits paid by a carrier can be paid directly to the provider.
Which of the following should always be collected from the patient at the time of service?
copay A copay should be collected at the time of service, if the patient's policy requires a copay. A deductible will not be known until the EOB comes back to the office. The maximum out of pocket is a monetary value, but is not a type of payment. Coinsurance is all money owed by the patient after an insurance company pays.
After a statement was received, the patient called to ask why a balance is due on the account. Which of the following would apply? (Select the three (3) correct answers.) A. copay B. co-insurance C. deductible D. premium E. overpayment
copay, co-insurance, deductible Copay, coinsurance, and deductibles are all paid by the patient to the provider. An insurance and coding specialist should tell the patient about all of these when discussing any payment owed to the provider. Premiums are also paid by the patient to the insurance carrier for insurance coverage. Overpayments can sometimes be made by the insurance carrier to the physician.
Which of the following information is required to submit a workers compensation claim? (Select the three (3) correct answers.)
date of Injury, employer name, employer's address When submitting a worker's compensation claim, the date of injury, the employer's name, and the employer's address must be provided because the claim will be paid through the employer's policy, not the patient's personal policy.
Which of the following is contained in an EOB? (Select the three (3) correct answers.)
deductible applied to visit, contractual adjustments, dollar amount paid An Explanation of Benefits (EOB) shows services billed to the insurance company and how the claim was adjudicated (processed) by the payer. Information included on an EOB includes the deductible amount applied to visit, contractual adjustments and the dollar amount paid to the provider. Due to patient privacy concerns, a patient's SSN and diagnosis are never included on an EOB.
Who is the policy holder of a Workers' Compensation policy?
employer The employer pays a fee for the policy that covers employees during their work hours. An employee policy is one purchased by the employee to cover illness and/or injuries for themselves and family members, but not work injuries.
Which of the following items must be completed on a patient registration form? (Select the three (3) correct answers.)
home address, insurance, DOB A patient registration form includes all of the patient demographics, including name, insurance, address, date of birth, and employment information. The patient registration does not include any medical information, since this form will serve as the base for all future visits.
Under which of the following circumstances does a patient need a referral from their PCP?
if the insurance plan is an HMO: Members who enrolls in a Health Maintenance Organizations (HMO) policy will only have coverage if the patient selects a provider who is in the HMO network. If a patient chooses a provider who is not in the HMO network and does not follow proper steps to obtain a PCP authorization or referral, the patient will be responsible for 100% of the billed charges each time the patient receives services from the out-of-network provider.
Which of the following should the insurance and coding specialist include when completing a CMS 1500 to submit to an insurance company? (Select the three (3) correct answers.)
insurance ID, provider ID number, place of service When completing a CMS-1500 form, patient demographics, provider demographics, and specifics of the visit (including services and diagnosis) are required. Medical record number is not required, as it is used only in the provider's office to identify patient records. It is also not required to provide the enrollment date, as that will already be connected to the insurance ID number.
When a patient fills out an intake form upon registration, which of the following vital information is needed on the form in order for the provider to get proper reimbursement for services?
insurance information and a copy of the card so that a claim can be sent to the insurance carrier The Insurance ID card often lists additional information that the patient might not include on a registration form such as insurance company phone numbers and preauthorization/precertification numbers. It is also common for a patient to transpose or omit identifying alphabetical characters or numbers or both. It is important to have the copy of the card as a reference to verify information is correct.
The purpose of the Explanation of Benefits is to
list the services rendered and payments by the insurance company. An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid.
In which of the following claim scenarios should an insurance and coding specialist submit an appeal? A. The payer requested a letter of medical necessity for an expensive supply item. B. The physician did not submit the claim in a timely manner due to unusual circumstances. C. The physician believes she received a large overpayment for the claim billed. D. The physician disagrees with the timeliness of the payment.
manner due to unusual circumstances. An appeal is filed when the insurance specialist believes that a claim has been underpaid or incorrectly denied. "The payer requested a letter of medical necessity for an expensive supply item" is an action by the payer and not the provider, so this option is not correct. "The physician did not submit the claim in a timely manner due to unusual circumstances" would require an appeal if requesting reimbursement for a claim that was not filed in a timely manner, so this is the correct option. "The physician believes she received a large overpayment for the claim billed" requires a refund from the provider not an appeal, so this option is not correct. "The physician disagrees with the timeliness of the payment" indicates that the payment was late which may require interest from the payer, but no appeal is necessary so this option is not correct.
Eligibility for Medicaid may change as quickly as
monthly.
The Medicare Secondary Payer Questionnaire is a form that
patients fill out to determine if there is other insurance designated as the primary insurance.
After a patient is seen for a follow up visit, the physician orders additional diagnostic testing. Which of the following does the insurance and coding specialist need to obtain?
pre-authorization: A billing and coding specialist must obtain a pre-authorization for the diagnostic testing. A pre-authorization is approval from the insurance company for the testing to be done. An allowed amount is not obtained until receiving the explanation of benefits, after the service is completed. A referral is needed to see a specialist, in some situations, and is provided by the primary care physician. An advanced beneficiary notice is a statement that is signed by the patient when it is known that the insurance company will not pay for the service and the patient is electing to have the service anyway. It is a promise that the patient will pay for the services in full.
In an HMO, plan members are required to obtain a referral to a specialist from the
primary care physician: A referral must by written by the primary care physician for a patient with an HMO insurance plan prior to seeing a specialist in the office. The primary care physician acts as a "gate keeping" for all healthcare provided for the patient. A rendering physician is not correct because a rendering physician is any physician who is providing treatment, including the primary care physician or specialist. Attending physicians are in the hospital setting. A consulting physician is a specialist.
The family physician wants to send the patient to the endocrinologist for management of the patient's newly diagnosed disease. The insurance and coding specialist should submit a request to the insurance company for a
referral. When a family physician wants to send a patient to a specialist, such as an endocrinologist, the insurance and coding specialist should submit a request for a referral to the insurance company. The insurance company will determine whether a referral is required for the patient or not.
Which of the following information will be required for an HMO that may be unnecessary for a PPO when submitting a CMS-1500 form?
referring physician The name of the referring physician must be included on the CMS-1500 billing form when billing an HBO. With a PPO plan it is not required to have a referring physician since the patient can see a provider of choice. On the CMS-1500 form the birthdate, insurance name, and diagnosis is a requirement for all claims filed.
When submitting a request for a pre-authorization, the billing and coding specialist should
submit codes for any scenario that may arise during the procedure: When submitting for a pre-authorization, the billing and coding specialist should use codes for the most complicated service that may be provided. For example, if a physician expects to do a stab phlebectomy, with 18 incisions, the person who is completing the pre-authorization should submit code 37766 (stab phlebectomy, more than 20 incisions) instead of code 37765 (stab phlebectomy, 10-20 incisions), in case the procedure is slightly more complicated than expected. Pre-authorizations are typically valid for 6 months. It is a good idea to acquire the pre-authorization as early as possible prior to the procedure date within the 6-month window, in case the surgery is postponed for any reason.
Which of the following must be included when completing a CMS-1500 form for a Workers' Compensation case? (Select the two (2) correct answers.)
the place of employment, date of injury The place of employment is necessary so the insurance company can identify the policy holder. The date of injury is must be documented to identify that the claimant was at work at the time of the injury. The patient's primary health insurance will not be used for claims purposes since the injury happened at the place of employment. The length of employment is not a factor, only that the claimant is employed at the time and place of injury.
Workers' Compensation policy guidelines are determined by
the state government. Workers' Compensation guidelines differ by state. Each state government is responsible for publishing its guidelines. The federal government does not determine Workers' Compensation guidelines. OSHA is the Occupational Safety and Health Administration and deals with safety in the workplace, but does not deal with workers' compensation benefits. An employee's human resource department does not determine workers' compensation guidelines.
If a married couple is covered under both spouses' health insurance and the husband is picking up a prescription for himself, he should
use both of insurance benefits as they apply to this pharmacy purchase.
Which of the following processes requires checking and confirming that the patient is a member of the insurance plan and that the member identification number is correct?
verification
A patient has just left the doctor's office with a new prescription after a scheduled follow up visit. If the patient's primary insurance covers the bill completely, her secondary insurance policy
will not be used for this visit.
The patient is a 3-year-old. Both parents have private insurance coverage on the patient, and the mother has a Healthcare Savings Account. The primary insurance belongs to the parent
with the earlier birthday in the year.
Patient has a bill of $1,000.00 and his portion due is $590.00. The insurance payment portion is $410.00. The patient wants to know why he owes more than the insurance. Which of the following actions should the insurance and coding specialist take? A. Provide the insurance company's phone number, and tell patient they must speak with the insurance. B. Provide the patient with a copy of the office fee schedule and financial policy. C. Print out a copy of the patient's account, and review the charges and responsibilities for payment with patient. D. Tell patient you will contact the insurance on their behalf, and have the insurance company call them to review the bill.
Print out a copy of the patient's account, and review the charges and responsibilities for payment with patient. In any situation where the patient is questioning a bill or money owed, the insurance and coding specialist should print out a copy of the patient's account and review the charges and responsibilities for payment with the patient. The insurance and coding specialist should be prepared to discuss allowed amounts, copayments, deductibles, and coinsurances with the patient.
Which of the following is the best time to collect a co-pay from the patient?
Prior to services being provided. A copayment must be made, by the patient, prior to seeing the physician and the services being rendered.
Which of the following statements is true about deductibles? A. The deductible is paid quarterly. B. The patient pays the deductible to the insurance company. C. The deductible is figured annually. D. Patients must pay the deductible even if they have not received services.
The deductible is figured annually. Rationale The deductible due from the patient is figured annually per calendar year. Usually January 1st through December 31st. This is paid to the provider from the patient as the claims are processed throughout the year.
Which of the following statements is true for an employee on Medicare if he chooses coverage under the employer's group plan?
The group plan will be primary and Medicare will be secondary.
A child was seen by her pediatrician. The child is covered under both her father's and mother's insurance. According to the "Birthday Rule," the mother's insurance is primary. Why?
The mother's birthday comes first in the calendar year.
Which of the following determines the primary policy if two plans cover a dependent child?
The parent who has the first birthdate of the year.
The insurance and coding specialist just received an EOB from the insurance carrier. The first patient listed has had four services. For all of these services, the allowable amount is the same as the billed amount. Why is that?
The patient has seen a nonparticipating provider. The billed amount on an EOB is the full price that a physician would charge for a service, without any discounts. The allowed amount on an EOB is the discounted price for seeing a participating provider (a physician who is in the covered network).
Which of the following is true when collecting patient's copay?
The patient is obligated to pay the copayments. The copay is the contracted amount the patient is required to pay for each office visit for treatment by the physician. The copayment amounts cannot be adjusted off of the patient account.
Which of the following is likely to be a cause for delay in receiving prior approval for a procedure or service from the insurance company?
The procedure submitted is not included on the policy: The procedure submitted not on the policy would be considered to be an exclusion to the policy or requires special consideration of medical necessity with the insurance company. A resident is not required to be credentialed as they are employees of the facility. A procedure taking longer than usual, requires a modifier, not prior approval.
Which of the following are valid reasons to file an appeal? (Select the three (3) correct answers.) A. ABN was not obtained for a non-covered service. B. The procedure was medically necessary. C. Inadequate payment was received for the procedure. D. Precertification was not on the initial submission. E. The physician disagrees with the pre-existing condition.
The procedure was medically necessary., Inadequate payment was received for the procedure., Precertification was not on the initial submission. A service can be denied for many reasons, including being denied for medical necessity, missing information, such as a precertification or authorization number, or for the place of service. These denials can be appealed with the corrected information. Another reason that an appeal might be sent is for inadequate payment received. When sending a denial, the insurance and coding specialist must defend the information sent or correct the previous mistakes. Denials for not obtaining an Advanced Beneficiary Notice or disagreeing with the pre-existing conditions are not acceptable reasons for filing an appeal.
A patient was hurt at work and seen in the physician's office today. The patient is covered under Medicare and BCBS and is also covered under Workers' Compensation for this injury. Which of the following is the primary insurance and the secondary insurance?
Worker's Compensation is the primary, BCBS is the secondary: The patient was injured at work so Worker's Compensation is the primary insurance carrier. Once the claim is processed through Worker's Compensation, it would follow the standard of the patient's health insurance claim process. Since the patient is working and covered under the employers' policy, the claim should be filed with BCBS as the next step of submission and the claim would be filed with Medicare last.
In each calendar year, a specified amount is to be satisfied before benefit payments can be made by the insurance plan. This specified amount is called
a deductible. The deductible must be paid in full, by the patient, before the insurance will pay anything for services. Coinsurance is the patient's responsibility, after the deductible has been met and after the insurance pays his portion. A copay is paid by the patient before services are rendered. Coinsurance, deductible, and copay are all called "out of pocket expenses", as the patient is responsible for all of them.
A patient, who has an HMO insurance policy, goes to the urologist's office. Before the urologist will see the patient, the patient must have
a referral. This provider is considered a specialist so a referral would be required from the primary care provider. Precertification or prior authorization refers to the process by which a patient is pre-approved for coverage of a specific medical procedure or prescription drug. An Advanced Beneficiary Notice is used for Medicare patients to explain when a procedure may not be covered for the patient.
Which of the following information will be found on an explanation of benefits? (Select the three (3) correct answers.)
amount billed by the provider, co-payment amount due from the patient, deductible amount subtracted from billed amounts An explanation of benefits (an EOB) is a financial breakdown of charges submitted, sent from the insurance carrier to the provider. It will state information such as the amount billed by the provider, the copayment due by the patient, the deductible owed, and the allowed amounts.
A pre-certification is
an approval from the insurance carrier to perform a service: A pre-certification is an approval from the insurance carrier that a service is medically necessary and can be performed. A pre-certification does not guarantee payment for the service. The payment depends on many more factors, such as any other procedures performed, the patients changed condition, and the way that the service is coded.
You are filing a claim for a hospital stay for a patient. The patient has Medicare Part
A Medicare Part A is hospital insurance. Medicare Part B is for outpatient services, such as office visits or lab tests. Medicare Part C is for additional private health plans. Medicare Part D is for prescription drugs.
