Quiz Chapter 12 & 15

The insured's name is found in block:

4.

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

Access to specialized care and referrals is limited.

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 methods can be used to determine a patient's eligibility for insurance?

Calling the provider services number on the back of the health insurance ID and using the provider web portal sponsored by the patient's health insurance company

Which part of Medicare covers prescription drug services?

D

The patient billing record includes which of the following information?

Demographic information

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

Medicaid.

Patients belonging to a MCO usually are required to get a referral from their ____ before seeing a specialist.

PCP

d) All are correct

Part B

Which of the following is typically documented in the explanation of benefits (EOB)?

Patient's deductible and co-insurance

Patient care approached from a holistic approach defines:

Patient-centered medical home

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

Physician's office visits

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

Preventive care and procedures deemed medically necessary

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 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

The provider is paid a set amount for each enrolled person assigned to them, per period of time, whether or not that person has received services is the definition of:

capitation.

After the deductible has been met the policyholder is responsible for a certain percentage of the bill is the definition of:

co-insurance.

A set dollar amount that the patient must pay for each office visit is the definition of:

copayment.

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

copayment.

Medigap polices cover which of the following? a) Medicare deductible b) Medicare co-insurance c) Services not covered under Medicare d) All are correct

d) All are correct

Which of the following steps is needed to obtain precertification? a) Call provider services phone number on the back of the patient's health insurance ID card. b) Provide the insurance company with procedures/services requested and the diagnoses. c) Document the outcome of the call in the patient's health record. d) All are correct

d) All are correct

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

deductible.

eligibility.

deductible.

Which of the following managed care plans require preauthorization for medical services such as surgery? a) HMOs b) PPOs c) EPOs d) HMOs and PPOs e) All are correct

e) All are correct

Meeting the stipulated requirements to participate in the healthcare plan is the definition of:

eligibility.

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

group policy.

If the ICD-10-CM codes and the CPT/HCPCS codes do not match the claim will not show __________.

medical necessity

Services and/or supplies used to treat the patient's diagnosis meet the accepted standard of medical practice is the definition of:

medical necessity.

The first step in filing a claim with a third-party is:

obtain accurate billing information from the patient.

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

participating

How many diagnoses can be reported on the CMS-1500?

Twelve

Which of the following steps to medical billing should be performed prior to rendering medical services?

Verify the patient's eligibility for insurance coverage and collect patient insurance information.

Claims that are done by direct billing first go to a clearinghouse. True False

False

Dirty claims cannot be resubmitted. True False

False

Only physicians can be providers of medical services. True False

False

When the birthday rule is used to determine which policy is primary and which is secondary, it is the policy of the person who is the oldest that is considered primary. True False

False

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

HMOs

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

TRICARE.

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.

Insurance information should be collected on the first visit. True False

True

To settle or determine judicially is the definition of:

adjudicate.

To examine claims for accuracy and completeness before they are submitted is to _________ the claims.

audit

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

beneficiary.

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

premium.

Organizations that fund their own insurance programs offer their employees:

self-funded plans.

Electronic data interchange is:

transferring data back and forth between two or more entities.

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

workers' compensation.