Final Review Flashcards
Define co-insurance:
Percentage of charges shared between the insurance plan and the patient
Define Fee Schedule:
Provider’s list of charges for services and procedures
The type of managed care that requires you to use your PCP as the “gatekeeper”?
HMO
Define PAR:
Provider who participates in an insurance plan
An EOB is also called what?
RA (Remittance Advice)
Define assignment of benefits:
Ensures providers receive payments directly from the insurance
What is coordination of benefits?
Prevents payment duplications when patient have more than one policy.
What is Medi/Medi and who qualifies for it?
Elderly patients who can get Medicare, but cannot pay for Medicare’s charges
True/False: A claims clearinghouse reviews information for errors (called scrubbing) before sending to insurance for payment
True
Which health program’s member eligibility depends of the individual’s income?
Medicaid
True/False: When a claim is submitted electronically, the Remittance Advice will be received electronically
True
What percentage of hospitalization, up to 60 days’ stay, does Medicare Part A pay?
100
What are the two main parts of Medicare?
A and B
Medicare Part B covers what services?
Outpatient services
What is the patient’s coinsurance with Medicare Part B?
20%
The majority of demographic information used on a claim is entered when?
Before the appointment time
What do we code for using the CPT manual?
Procedural codes
What are the two main sections of the ICD-10 manual?
Alphabetic index and tabular list
What is a review of allowable benefits?
Comparing physician fees to patient’s health plan benefits
An insurance policyholder can also be called what?
Subscriber
The diagnosis is coded using which manual?
ICD-10 CM
What are the two major types of health plans?
Managed Care Organization and Fee-for-Service
Which managed care program requires members to receive treatment only from one of it participating providers?
HMO
What health care reform was enacted in 2010 to make healthcare more affordable?
Affordable Care Act
Which codes are often considered the most important because they are used most frequently?
Evaluation and Management
When a person becomes eligible for social security they are also automatically enrolled in what health benefits program?
Medicare (Part A)
What is the name of the claim form you are required to use to submit paper claims?
CMS-1500
Who is eligible for Tricare?
Active duty and retire military personnel
Who is covered by ChampVA?
Veterans with total, permanent, service-related disabilities
What entity is considered a third-party payer?
The health plan
List all the government sponsored health insurance plans?
Medicare, Medicaid, Tricare, ChampVA
How is eligibility for ChampVA determined?
Patient’s nearest VA facility
What is Medicaid?
Program for low-income individuals and children
