Insurance

Question 1

Advanced 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 a third-party payer will pay for a particular procedure or service

Amount insurance company allows Dr to charge for service

Question 3

Copayment

Answer 3

A fixed amount, out of pocket expense paid at the time of medical service

Question 4

Coinsurance

Answer 4

A policy provision in which the policyholder and the insurance company share the cost of covered medical services in a specified ratio such as 80:20

% of visit out of pocket expense

Question 5

Deductible

Answer 5

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

Question 6

Explanation of Benefits (EOB)

Answer 6

A statement from an insurance carrier describing what services were paid, denied, or reduced in payment

And also contains info about amounts applied to 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

Question 8

Federal and State government insurance plans

Answer 8

-Medicare

-Medicaid

-Tricare

-CHAMPVA

-managed care plans

-workers’ compensation

Question 9

Medicare

Answer 9

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

Question 10

TRICARE

Answer 10

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

Question 11

CHAMPVA

Answer 11

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

Question 12

Medicaid

Answer 12

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

Question 13

Managed Care

Answer 13

an umbrella term for plans that provide health care in return for preset scheduled payments and coordinated care through a defined network of providers and hospitals

Question 14

Workers Compensation

Answer 14

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

Question 15

Private Insurances

Answer 15

-Blue Cross Blue Shield (America’s oldest and largest system)

-Aetna

-United Healthcare

Question 16

Healthcare Delivery Models

Answer 16

organization of individuals,establishments, and resources to deliver healthcare services and meet the health needs of specific populations

Question 17

HMO

Answer 17

Patients are restricted to network and may not see a specialist without a a referral or acquire coverage for service received outside of network

Question 18

PPO

Answer 18

preferred provider organization

Greater flexibility by having freedom to visit any provider but has increased cost and decreased coverage for out of network

Question 19

CMS-1500 Form

Answer 19

Health insurance claim form

the standard form used by health-care providers to bill for services, including disease state management services

Question 20

CMS-1500 Form Sections

Answer 20

Form has 33 blocks or items divided into 3 sections:

Section 1: Carrier Block

Section 2: Patient/Insured Section

Section 3: Physician/Supplier Section

Question 21

Section 1: Carrier Block

Answer 21

contains the address of the insurance carrier and is located at the top of the form

Question 22

Section 2: Patient/Insured Section

Answer 22

contains information about the patient or insured (if other than the patient); includes boxes 1 through 13.

Question 23

Section 3: Physician/Supplier Section

Answer 23

contains information about the physician or supplier: includes boxes 14 through 33.