Chapter 17 Practice 1: Explanation of Benefits

The maximum amount an insurance carrier or program will pay for specified services when the physician is a participating provider in the program

Allowable charge

The amount the insurance carrier pays for the medical service

Amount due from insurance carrier

The difference between either (1) the total charge or (2) the allowable charge and the total amount due from all insurance carriers for services the patient's contract covers

Amount due from patient

The patient's payment of a portion of the cost at the time of the medical service

Coinsurance (copayment)

The dollar amount that the insured must pay before a medical insurance policy or program will begin to cover the healthcare costs

Deductible

How much does the insured owe (not including the copayment, which has already been paid)? In this case, the patient is responsible for the disallowed charge. a. $14.00 b. $55.00 c. $10.00 d. $52.00

a. $14.00

What is the amount that exceeds the reasonable and customary price scale? a. $26.00 b. $121.00 c. $67.00 d. $34.00

a. $26.00

Since there is $0.00 applied to the deductible, the _____. a. deductible has already been met b. submitted charge was too low to require an amount applied to the deductible c. copayment covers the deductible d. disallowed charge covers the deductible

a. deductible has already been met

What is the maximum amount the insurance carrier will allow for this particular service? a. $147.00 b. $26.00 c. $121.00 d. $34.00

c. $121.00

What is the amount that exceeds the reasonable and customary price scale? a. $79.00 b. $65.00 c. $14.00 d. $55.00

c. $14.00

How much does the insured owe (not including the copayment, which has already been paid)? In this case, the patient is not responsible for the disallowed charge. a. $121.00 b. $87.00 c. $67.00 d. $93.00

c. $67.00