chap 12

A review of individual cases by a committee to make sure that services are medically necessary is called a(n):

utilization review.

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

workers' compensation.

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:

explanation of benefits.

A list of the fixed fees for services is a:

fee schedule.

In some managed care plans referrals to a specialist must be approved by the:

gatekeeper.

Someone who is poor, needy, or impoverished is considered:

indigent.

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

medically necessary.

The provider who enters into a contract with an insurance company and agrees to certain rules and regulations is called a ______ provider.

participating

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

policy

A process required by some insurance carriers in which the provider obtains permission to perform certain procedures or services is:

preauthorization.

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

premium.

Service provided to stop certain conditions from occurring or to lead to an early diagnosis are considered:

preventive.

An order from a primary care provider for the patient to see a specialist is a(n):

referral.

Organizations that fund their own insurance programs offer their employees:

self-funded plans.

Which of the following is not a disadvantage of managed care?

Authorized services usually are covered.

Which part of Medicare covers prescription drug services?

D

Health insurance typically covers 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

There are no government managed care plans.

False

A certain percentage of the allowed amount that the policyholder is responsible for is:

co-insurance.

A set dollar amount that the policyholder must pay for each office visit is:

copayment.

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

deductible.

Which type of referral is usually processed immediately?

STAT

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

STAT referral

A designated person who receives funds from an insurance policy is:

beneficiary.

A formal request for payment from an insurance company for services provided is:

claim.

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?

$3087.20

Which of the following is not an advantage of managed care?

Access to specialized care and referrals is limited.

Medigap polices cover which of the following?

All are correct

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

All are correct

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

All are correct

Which of the following managed care plans require preauthorization for medical services such as surgery?

All are correct

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

HMOs

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

Medicaid.

Which part of Medicare covers inpatient hospital charges?

Part A

Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium?

Part B

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

TRICARE

Veterans of the U.S. armed forces may be covered by:

TRICARE.

A provider can choose whether to accept Medicaid patients.

True

Nearly all of the provider's income is derived from the insurance payments received for services rendered.

True

TRICARE is a form of government insurance for veterans of the U.S. armed forces.

True