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

medically necessary. elective. provider network. preventive.

An organization that processes claims and provides administrative services for another organization is:

third-party administrator

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

utilization review.

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.

capitation

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

claim

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

Which part of Medicare covers prescription drug services?

d

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

deductible.

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.

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 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

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

group policy.

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

health maintenance organizations

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

indigent

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

part b

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

participating

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 $4359 ?2- $500= $3859 $3,859 × 0.8 = $3,087.20.

RBRVS consists of three parts, including which of the following?

All are correct Charge-based professional liability expenses Charge-based overhead Provider work

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

All are correct Effective date of insurance Eligibility Benefits and exclusions

Which of the following plans require healthcare providers to become participating providers?

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

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

Authorized services usually are covered

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

CHAMPVA

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

Access to specialized care and referrals is limited.

Which type of referral is usually processed immediately?

STAT

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

Medicaid.

Medigap polices cover which of the following?

Medicare deductible Correct Answer All are correct Medicare co-insurance Services not covered under Medicare

Which of the following services must be covered by Medicaid in each state?

Nurse Midwife services Transportation of medical care Family planning services Correct! All are correct

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

PPOs HMOs HMOs and PPOs EPOs Correct! All are correct

Which part of Medicare covers inpatient hospital charges?

Part A

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

Physician's office visits

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

Prescription drugs Emergency services Correct! All are correct Laboratory services

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

Preventive care and procedures deemed medically necessary

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 offer limited benefits, and healthcare access is limited to healthcare providers that are contracted with them.

The first statement is true; the second is false.

A provider can choose whether to accept Medicaid patients.

True

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

True

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

beneficiary.

Which of the following are not reviewed by a utilization review committee?

Fees for services provided

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

HMOs

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

TRICARE

Health insurance designed for military dependents and retired military personnel is called:

TRICARE

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 approved list of physicians, hospitals, and other providers is a(n):

provider network.

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

referral.

The allowed amount for Medicare charges is determined using:

resource-based relative value scale.

Organizations that fund their own insurance programs offer their employees:

self-funded plans.

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

workers' compensation

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

The health insurance model that offers the most flexibility for patients is:

traditional health insurance

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

true