Final Review

Question 1

Define co-insurance:

Answer 1

Percentage of charges shared between the insurance plan and the patient

Question 2

Define Fee Schedule:

Answer 2

Provider’s list of charges for services and procedures

Question 3

The type of managed care that requires you to use your PCP as the “gatekeeper”?

Answer 3

HMO

Question 4

Define PAR:

Answer 4

Provider who participates in an insurance plan

Question 5

An EOB is also called what?

Answer 5

RA (Remittance Advice)

Question 6

Define assignment of benefits:

Answer 6

Ensures providers receive payments directly from the insurance

Question 7

What is coordination of benefits?

Answer 7

Prevents payment duplications when patient have more than one policy.

Question 8

What is Medi/Medi and who qualifies for it?

Answer 8

Elderly patients who can get Medicare, but cannot pay for Medicare’s charges

Question 9

True/False: A claims clearinghouse reviews information for errors (called scrubbing) before sending to insurance for payment

Answer 9

True

Question 10

Which health program’s member eligibility depends of the individual’s income?

Answer 10

Medicaid

Question 11

True/False: When a claim is submitted electronically, the Remittance Advice will be received electronically

Answer 11

True

Question 12

What percentage of hospitalization, up to 60 days’ stay, does Medicare Part A pay?

Answer 12

100

Question 13

What are the two main parts of Medicare?

Answer 13

A and B

Question 14

Medicare Part B covers what services?

Answer 14

Outpatient services

Question 15

What is the patient’s coinsurance with Medicare Part B?

Answer 15

20%

Question 16

The majority of demographic information used on a claim is entered when?

Answer 16

Before the appointment time

Question 17

What do we code for using the CPT manual?

Answer 17

Procedural codes

Question 18

What are the two main sections of the ICD-10 manual?

Answer 18

Alphabetic index and tabular list

Question 19

What is a review of allowable benefits?

Answer 19

Comparing physician fees to patient’s health plan benefits

Question 20

An insurance policyholder can also be called what?

Answer 20

Subscriber

Question 21

The diagnosis is coded using which manual?

Answer 21

ICD-10 CM

Question 22

What are the two major types of health plans?

Answer 22

Managed Care Organization and Fee-for-Service

Question 23

Which managed care program requires members to receive treatment only from one of it participating providers?

Answer 23

HMO

Question 24

What health care reform was enacted in 2010 to make healthcare more affordable?

Answer 24

Affordable Care Act

Question 25

Which codes are often considered the most important because they are used most frequently?

Answer 25

Evaluation and Management

Question 26

When a person becomes eligible for social security they are also automatically enrolled in what health benefits program?

Answer 26

Medicare (Part A)

Question 27

What is the name of the claim form you are required to use to submit paper claims?

Answer 27

CMS-1500

Question 28

Who is eligible for Tricare?

Answer 28

Active duty and retire military personnel

Question 29

Who is covered by ChampVA?

Answer 29

Veterans with total, permanent, service-related disabilities

Question 30

What entity is considered a third-party payer?

Answer 30

The health plan

Question 31

List all the government sponsored health insurance plans?

Answer 31

Medicare, Medicaid, Tricare, ChampVA

Question 32

How is eligibility for ChampVA determined?

Answer 32

Patient’s nearest VA facility

Question 33

What is Medicaid?

Answer 33

Program for low-income individuals and children