Ch 6
"T"
"Reasonable and customary" is a term used to refer to the commonly charged or prevailing fees for health services within a geographical area.
"T"
23. A model of care in which primary provider manages and coordinates the care of all elements of a patient's health with a team of healthcare providers is called patient-centered facility care.
Fee schedule
A comprehensive listing of medical charges is referred to as
"T"
A consumer-directed health plan (CDHP) often involves pairing a high-deductible PPO plan with a tax- advantaged account, such as a health savings account (HSA).
"T"
A health savings account (HSA) is a tax-advantaged account in which money can be set aside to pay for future medical expenses.
"F"
A high-deductible health plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan.
Third party administrator
A person or organization that processes claims and performs other contractual administrative services is commonly referred to as a
Participating provider
A provider who signs a contractual arrangement with a third party insurance
Health insurance exchanges
A set of state-regulated and standardized health care plans in the United States, from which individuals may purchase health insurance eligible for federal subsidies.
"T"
A third-party payer is any organization that provides payment for specified coverage provided under a health plan.
All of the above
An example if a third payer party
"T"
An explanation of benefits (EOB) is a document prepared by the carrier that gives details of how the claim was adjudicated
"T"
BCBS offers only fee-for-service plans.
indemnity pool
Before the affordable care act was signed into law, individuals who had been denied coverage because of a preexisting condition and had been without coverage for at least 6 months could acquire healthcare insurance through a
Credible coverage
Before the affordable care act, a persons health insurance coverage that has been in effect for a specific number of days before enrolling in a new health plan is called
"T"
Blue Cross and Blue Shield organizations are no longer governed at a national level, and each has its own specific guidelines for completing the CMS-1500 claim form.
"T"
Blue Cross policies cover inpatient hospital care; Blue Shield covers physicians' services.
"F"
Commercial health insurance is standard in price and the kinds of benefits that the policy covers.
"F"
FFS plans all have the same deductible amount.
"T"
Filing CMS-1500 paper claims for commercial carriers is much the same as with all other carriers.
Benefit
For americans today accessibility to healthcare is viewed as a
"F"
Group insurance is generally more expensive because it covers more individuals.
A contract between an insurance company and an employer
Group insurance typically is:
"F"
HIPAA mandates that all commercial claims be submitted electronically
Everyone who enrolls in a plan under ppaca pays the same premium
Identify which of these is not true under the patient protection and affordable care act of 2009
"F"
If an individual belongs to a BlueCard PPO, the initials PPO appear inside a blue globe.
"T"
It is important to consult all types of insurance plans for their specific guidelines to avoid claim delays and rejections.
"T"
Medicare fiscal intermediaries (FIs) and carriers are now more commonly referred to as Medicare administrative contractors (MACS).
"T"
Most organizations that are self-insured are large entities, which can draw from hundreds or thousands of enrollees
"T"
Normally, when husband and wife are covered under separate policies, primary coverage follows the patient.
"F"
One objective of an Integrated Delivery System is (IDS) improving quality of care while lowering patient cost.
Med rule
People who were covered under an employer sponsored group plan before the enforcement of the affordable care act can usually keep their group coverage as long as the plan meets the :
All of the above
Standard costs associated with healthcare plans include the patient paying:
Minimal essential coverage
The affordable care act states that by 2014, everyone in the US should have access to a comprehensive set of healthcare benefits
No one type is universally best
The best type if healthcare plan
Employee Retirement Income Security Act (ERISA)
The federal law designed to protect the rights of beneficiaries of employee benefit plans offered by employers and that sets minimum standards for pension plans in private industry is called:
FEHB program
The government health insurance program that provides coverage for its own civilian employees is called
Patient Protection and Affordable Care Act
The legislation that includes a mandate that insurance companies must cover certain preventive services for those who purchased or joined a new plan on or after sept 23, 2010
"F"
The time limit for filing claims is the same for all third-party payers-1 year
Managed care plan and ffs plan
The type of heath insurance that offers the most choices of physicians and hospitals in which patients can choose any provider they want and can change providers at any time is an:
"T"
Today, insurers are encouraged to structure their reimbursement models based on the quality and utility of care provided rather than the sheer volume of services.
Self insured program
When the employer--not an insurance company--is responsible for the cost of its employees' medical services, the employer has a:
Reasonable and customary
When the fee charged by a provider falls within the parameters of the fee commonly charged for that particular service within a specific geographic area, it is said to be:
"T"
With FFS insurance, the policyholder controls the choice of physician and facility
"F"
With fee-for-service plans, patients can choose any physician they want and change physicians at any time.
