Chapter 13 Insurance

Question 1

Third party payer

Answer 1

Any payment for medical services that are not paid by the patient or physician

Question 2

Eligibility for dependents

Answer 2

Unmarried natural or adopted child, stepchild, or legal guardianship until age 18 or 21; may be extended for disability or full time student

Question 3

Healthcare Savings Account

Answer 3

Payroll deductions to accounts that can only be used for medical care

Question 4

Deductible

Answer 4

Amount paid by the patient before the carrier begins paying

Question 5

Individual health benefits

Answer 5

Policy purchased by an individual from an insurance company

Question 6

What is the difference between Medicare Part A and Medicare Part B

Answer 6

Part A covers hospital expenses and provided at no additional cost to those eligible for social security

Part B is optional and a monthly fee is charged which is deducted from monthly SS benefits

Question 7

Crossover claim

Answer 7

Claim crosses over automatically from one coverage to the other

Question 8

6 items Medicaid covers at 100%

Answer 8

• Inpatient hospital care
• Outpatient treatment and services
• Diagnostic services
• Family planning
• Skilled nursing facilities
• Diagnostic screenings for children

Question 9

How often do Medicaid patients receive a new ID card?

Answer 9

Monthly

Question 10

Explanation of Benefits (EOB)

Answer 10

Explains how payment was made, including deductible and coinsurance information.

Question 11

Outiler

Answer 11

Patient who has an unusually long stay or complicated case.

Question 12

What information is needed to fill out a CMS-1500 form?

Answer 12

Diagnostic codes from encounter form

Question 13

Claims administrator

Answer 13

Individual who manages third party reimbursement policies for a medical practice

Question 14

co-insurance

Answer 14

aka co pay; The agreed upon amoutn paid to the provider by a policyholder

Question 15

Managed care

Answer 15

Third party payers control costs by requiring physicians to adhere to specific rules as a condition of payment

Question 16

PPO

Answer 16

Health benefit program that contracts with providers, then leases the network to health care plans

Question 17

What form do you fill out to submit insurance claim?

Answer 17

CMS-1500

Question 18

What does a gatekeeper physician do?

Answer 18

Primary care physician; manages the patient’s care by establishing a relationship with them, reduce plan cost of specialists

Question 19

Birthday rule

Answer 19

Primary insurance is decided by whose birthday comes first in the calendar year

Question 20

assignment of benefits

Answer 20

Transfer of the patient’s legal right to collect third party benefits to the provider of the services

Question 21

Capitation

Answer 21

Managed care plan; pays certain amount to provider over a specific time for caring for the patients in the plan

Question 22

How do you confirm a patients eligibility?

Answer 22

Contact the claims administrator listed on the insurance card

Question 23

When would a statement of unavailability be required for treatment by a physician’s office or civilian hospital for TRICARE patients?

Answer 23

When the patient lives within 40 miles of a uniformed services hospital and that facility is unable to handle the needs of the patient

Question 24

Utilization review or precertification

Answer 24

Patient can be admitted to hospital only if it was approved by the insurer

Question 25

HMO

Answer 25

An organization that provides services through a contract with a specified group and a predetermined payment