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Medical Assisting > Medical Insurance & Billing > Flashcards

Medical Insurance & Billing Flashcards

1
Q

Who is a first party payor?

A

patient

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2
Q

Who is a second party payor?

A

healthcare provider

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3
Q

Who is a third part payor?

A

health plan (insurance)

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4
Q

What is a deductible?

A

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

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5
Q

What is a coinsurance?

A

policyholder and insurance company share the cost of services (ex. 80:20)

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6
Q

What is a copayment?

A

amount of money paid at the time of service
- ex. primary care: $20
- ex. medications: $35

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7
Q

What is an assignment of benefits?

A

form signed by the patient to allow the provider to be paid directly by the insurance company

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8
Q

What is a participating provider?

A

providers that agree to write off the difference between that amount charged and the allowed amount by the insurance company

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9
Q

What is allowed amount?

A

maximum amount the insurance company will pay for a service or product

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10
Q

What is an advanced beneficiary notice? (ABN)

A

form given to patient when the provider believes medicare will not cover services
- patient must pay

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11
Q

What is an explanation of benefit? (EOB)

A

statement from insurance company to patient outlining amounts billed, amounts allowed, amounts applied to deductible, coinsurance, and copays

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12
Q

What is preauthorization? (precertification)

A

process of contacting the insurance plan to see if a procedure is a covered service under the patient’s insurance plan

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13
Q

Who is medicare for?

A

patient’s over 65 y/o

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14
Q

What is medicare part A?

A

hospitalization

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15
Q

What is medicare part b?

A

routine medical office visits and outpatient services

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16
Q

What is medicare part c?

A

optional additional coverage offered by private companies approved by medicare

17
Q

What is medicare part D for?

A

medications

18
Q

Who is medicaid for?

A

covers low income and mentally indigent

19
Q

Who is tricare for?

A

military personnel and dependants

20
Q

Who is CHAMPVA for?

A

surviving spouses and dependent children of veterans who have died due to service related disabilities

21
Q

What is CHIP? Who is it for?

A

children’s health insurance program
- low-cost health coverage to children in families that earn too much money to qualify for medicaid

22
Q

What is workers compensation?

A

covers workers against lost wages due to accidents on the job

23
Q

What is HMO?

A

contracts with providers and hospitals to provide preventative and acute care
- requires referrals to specialists
- requires preauthorization
- requires PCP

24
Q

What is PPO?

A
  • no referrals needed
  • in-network providers
25
Q

What is fee-for-service?

A
  • policy lists covered medical services
  • amount charged for services is controlled by the physician
  • amount paid for services is controlled by the insurance carrier
26
Q

What is pay-for-performance?

A

compensates providers only if certain measures are met for quality and efficiency

27
Q

What is capitation?

A

patient’s are assigned a per member per month payment based on age, race, sex, lifestyle, medical history

28
Q

What form is needed for electronic claim transmission?

A

CMS-1500

29
Q

What is in section 1 of the CMS-1500 form?

A

address of insurance carrier
- top of form

30
Q

What is in section of CMS-1500 form?

A

patient/insured section
- information about patient or covered person
- blocks 1-13

31
Q

What is in section 3 of CMS-1500 form?

A
  • physician/supplier section
  • boxes 1-33
32
Q

What is account receivable?

A

money owed to the provider for services rendered

33
Q

What is account payable?

A

debt incurred by not paid
- supplies or utilities

34
Q

Who is a guarantor?

A

person with financial responsibility for the patient

Medical Assisting (51 decks)

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