Insurance

Question 1

advance beneficiary notice (ABN)

Answer 1

a form provided to the patient when the provider believes Medicare will probably not pay for services received

Question 2

allowed amount

Answer 2

the maximum amount of money a third-party payer will pay for a particular procedure or service

Question 3

copayment

Answer 3

an amount of money that is paid at the time of medical service

Question 4

coinsurance

Answer 4

policy provision frequently found in medical insurance whereby the policyholder and the insurance company share the cost of covered losses in a specified ratio (ex: 80/20)

percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible

Question 5

deductible

Answer 5

the specified amount of money a patient must pay out of pocket before the insurance carrier begins paying

Question 6

explanation of benefits

Answer 6

a statement from the insurance carrier detailing what was paid, denied, or reduced in payment

contains information about amounts applied to the deductible, coinsurance, and allowed amounts

Question 7

participating provider (PAR)

Answer 7

providers who agree to write off the difference between the amount charged by the provider and the approved fee established by the insurer

the provider agrees to accept the amount approved by Medicare as the total payment for covered services. The deductible and/or coinsurance are applied to covered services and the beneficiary is responsible for these amounts

Question 8

Medicare

Answer 8

covers patients age 65 and older by Part A benefits (hospitalization) or Part B benefits (routine medical office visits)

Question 9

Tricare

Answer 9

authorizes dependents of military personnel to receive treatment from civilian providers at the expense of the federal government

Question 10

CHAMPVA

Answer 10

covers surviving spouses and dependent children of veterans who died as a result of service-related disabilities

Question 11

Medicaid

Answer 11

provides insurance to the medically indigent population through a cost-sharing program between federal and state governments for those who meet eligibility criteria

Question 12

Managed care

Answer 12

plans that provide healthcare in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals

(ex: Kaiser)

Question 13

Workers’ compensation

Answer 13

protects wage earners against the loss of wages and the cost of medical care resulting from an occupational accident or disease as long as the employee is not proven negligent

workers’ compensation provides medical expenses, lost wages, and rehabilitation costs to employees who are injured or become ill “in the course and scope” of their job. It also pays death benefits to families of employees who are killed on the job.

Question 14

CMS-1500 form

Answer 14

a health insurance claim form for claims submitted by a provider or supplier.

the MA must have all the information needed to complete the form:
1) patient’s and guarantor’s demographic & insurance information
2) test/treatment/procedure information
3) billing information.

33 blocks/items, 3 sections

Question 15

CMS-1500 form (Section 1)

Answer 15

carrier block

contains the address of the insurance carrier

Question 16

CMS-1500 form (Section 2)

Answer 16

patient/insured section

contains information about the patient or insured (if other than the patient)

boxes 1-13

Question 17

CMS-1500 form (Section 3)

Answer 17

physician/supplier section

contains information about the physician or supplier

boxes 14-33