MAST- Insurance Ch 18

Hazards, perils, or conditions listed in an insurance policy for which the company will not pay

exclusions

Specific conditions listed in an insurance policy for which the policy will not pay are

exclusions

The Medicare Comprehensive Error Rate Testing (CERT) program was established as part of the Improper Payments Information Act. What year this occur?

2003

The Patient Protection and Affordable Care Act was signed in 2010, and was designed to insure millions of poor and middle-income Americans in public and private programs. In what year did Americans begin signing up for this program?

2014

With health care reform, parents will be able to keep adult children on their policies until age

26

Which type of claim has been discarded by an insurance company's system because of technical errors and may be returned to the provider?

rejected

When a patient provides written authorization for a physician or health care facility to receive payment directly from a third party (insurer) for services, this is known as a/an

Assignment of benefits

Exceptions or reductions to coverage as outlined in a policy

limitations

State disability insurance is offered in

California, Hawaii, New Jersey, New York, Rhode Island, and Puerto Rico

Medicare physicians and practitioners

Can "opt out" of the Medicare program for 2 years.

Which of the following is a method of payment in which the physician is paid a set amount for each patient enrolled regardless of services provided?

Capitation

Which document is sent by private insurance carriers to detail amounts paid or denied on an insurance claim?

explanation of benefits

When submitting electronic claims, it is referred to as

ECT

A fiscal intermediary is an agency that conducts health care quality audits

False

A referral is the same as a consultation

False

Under which type of managed care plan will the cost of services be covered only if the patient receives care from a participating physician?

HMO

Health care reform assures that there will no longer be

Limitations on coverage, limits for lifetime maximum benefits, preexisting condition clauses (all of the above)

What is the acronym used for another payer is primary to Medicare?

MSP

A "taxonomy code" on a claim form is used to designate

a physician's specialty

Under which type of managed care plan can enrollees obtain services from nonparticipating physicians and pay a higher deductible and co-payment?

PPO

Hospital insurance benefits are provided under which part of the Medicare program?

Part A

When examining a Medicare card, which has been presented for services in a physician's office, be sure the patient has

Part B coverage

Payment made periodically to keep an insurance policy in force

Premium

Illness or injury that prevents an individual from performing one or more of the functions of a regular job

Partial Disability

Which type of claim is held in suspense by an insurance company for review or because additional information is needed before a payment determination can be maDE

Pending

Illness or injury that prevents an individual from performing all the functions of a regular job indefinitely

Permanent Disability

Obtaining advance approval from an insurance carrier for a service or procedure to be performed

Preauthorization

Anything that was treated before the policy was issued

Preexisting condition

A compilation of a physician's charges and payments made by an insurance company for specific services over a period of time is the physician's

Profile

Illness or injury that prevents an individual from performing the major duties of his or her occupation for a limited time period

Temporary Disability

Select the correct statement about health care premiums and benefits

The more expensive the higher the premium and the less out of pocket expenses

Determination of payment for an insurance claim

adjudication

Private insurance companies or government-funded health plans

Third Party Payers

Illness or injury that prevents an individual from performing the major duties of his or her specific occupation

Total Disability

Attachment to a policy that excludes certain illnesses or disabilities

Waiver

An insurance policy is a legally enforceable

contract

Request for payment under an insurance contract

claim

Cost-sharing in which an insured patient assumes a percentage of the cost of covered services

coinsurance

Cost sharing in which an insured patient pays a designated amount at the time of service

copayment

Amount the insured must pay in a calendar year before policy benefits begin

deductible

The spouse and/or children of the primary insured

dependents

Period of time after the onset of a disability for which no benefits will be paid

elimination period

An individual injury or work-related illness is a foreseeable event arising out of one's employment

false

A Medicaid patient's signature on an Advance Beneficiary Notice must be obtained

for all services medicare does not deem "medically necessary"

A "HDHP" is a/an

insurance health plan with a high deductible

A signed consent to release medical information for treatment, payment, and health care operations

is no longer mandates by HIPPA

Insurance policy designed to cover medical expenses resulting from injury or catastrophic or prolonged illness

major medical

patient having both Medicare and Medicaid is referred to as

medi/ medi case

What is the statement called that is sent to a Medicare patient summarizing the disposition of a claim in laymen's terms

medicare summary notice

For TRICARE patients, a Nonavailability Statement is needed when a patient lives within the hospital's ZIP code area and

nonemergency care is not available

With Health Care Reform, Medicare patients who now belong to Medicare Advantage Plans that earn higher incomes will soon

pay lower premium

The process of finding out if a service or procedure is covered under a patient's insurance policy is

precertification

Periodic payments made to keep an insurance policy in force are

premiums

Medicaid is a health assistant program sponsored by

state, federal, and local governments

What information must be copied from a patient's insurance card

the front and back of the card

The insured is the individual who contracts for and is covered by an insurance policy.

true

in workers' compensation cases, the contract exists between the physician and the insurance company

true

Physician charge profiles determine these rates

usual, customary, and reasonable