Basic Health Insurance MA105 EXAM 1

Question 1

Money/$ a mgd care plan requires patient to pay in the office prior to being seen by a provider

Accepted Answer

copay

Question 2

Can an insurance billing specialist plead ignorance to escape liability?

Accepted Answer

no

Question 3

Explain differences between implied & expressed contract

Accepted Answer

Implied=body language, not by direct words, expressed=verbal or written consent, Implied=deduced by circumstances, conduct of patient

Question 4

Define managed care

Accepted Answer

ins co decides what kind of care a member needs, ins co decides how much care a member needs, ins co decides who can provide services, method to control healthcare costs but allow healthy members

Question 5

Cost sharing requirement where the insured pays a percentage/% of the fees

Accepted Answer

coinsurance

Question 6

An insurance claim representative

Accepted Answer

claim adjudicator

Question 7

Describe a Flexible Spending Account/FSA

Accepted Answer

Employer sponsored acct; employer sets max limit

Question 8

Describe the differences between the terms Preauthorization, Precertification &Predetermination

Accepted Answer

D=Dollars; How much will the ins co pay-- max dollars, C=Covered/Contract; Is procedure covered under the contract, A=Approval; Is procedure covered & medically necessary

Question 9

What does the acronym CDHP stand for?

Accepted Answer

Consumer Driven Health Plan, Consumer Directed Health Plan

Question 10

A patient's financial accounting record

Accepted Answer

ledger

Question 11

What type of laws govern private ins plans & Medicare, Medicaid & Tricare?

Accepted Answer

Medicare/Medicaid/Tricare = federal laws, private plans = civil laws

Question 12

Define coordination of benefits

Accepted Answer

to ensure no duplicate pymts on services provided, determines order of ins co pymts when more than 1 ins plan

Question 13

In terms of the law, what is an insurance policy?

Accepted Answer

legally enforceable contract/agreement

Question 14

Describe what COBRA is & what does the abbreviation stand for?

Accepted Answer

Consolidated Omnibus Budget Reconciliation Act, employers with 20 or more employees must offer COBRA, healthcare extended up to 18 months, federal law requirement

Question 15

Guidelines for submitting ins claims when a physician has less than 10 employees

Accepted Answer

10+ employees = must submit electronic claims, 1-9 employees = paper claims okay

Question 16

Decision by health ins co to ensure services rendered match level of diagnosis/diagnoses

Accepted Answer

medically necessary

Question 17

Define emancipated minor

Accepted Answer

can be married, divorced, parent, in military, possesses decision making rights, lives independently, self supporting, under legal age per state (generally 18 years old)

Question 18

Person who legally signs & accepts responsibility to pay the bill

Accepted Answer

guarantor

Question 19

Other names for encounter forms; what's included & what's it used for in medical office?

Accepted Answer

charge slip, routing form, superbill, transaction slip, routing sheet & invoice to patient, multipurpose billing form, includes procedures & diagnoses, patient name, date, charges

Question 20

What are some other terms that are used to refer to an insured individual?

Accepted Answer

subscriber, policy holder, member

Question 21

Describe a Health Savings Account/HSA

Accepted Answer

regulated like IRA, unused funds roll over, employee makes contributionsfor eligible healthcare expenses, At retirement age may be used for non-medical expenses

Question 22

Define indemnity health insurance

Accepted Answer

max flexibility/choice of providers, traditional plan, fee-for-service plan

Question 23

Check & confirm that a patient is a member of insurance plan & the provided ID # is correct

Accepted Answer

eligibility verification

Question 24

Difference between par & non-par physician/provider

Accepted Answer

par has signed contract w/ins co & files claims, non-pars may request full pymt from patient, non-par has no contract w/ins co; may/may not file claims

Question 25

Under healthcare reform legislation, until what age can children be carried on insurance?

Accepted Answer

26 years old

Question 26

A specific amount of money paid before insurance policy benefits/$$ begin

Accepted Answer

deductible

Question 27

Describe a Health Reimbursement Account/HRA

Accepted Answer

employer owned account, employees make claims for eligible healthcare expenses, only employer can make contributions, employee submits to employer for claim refund

Question 28

Describe marketplace "exchanges"

Accepted Answer

internet site where one can purchase private ins plans, e-listing of private ins plans from local carriers, organized marketplace for individuals & smallbusiness owners

Question 29

Conditions existing & treated prior to the effective date of a policy

Accepted Answer

pre-existing exclusion

Question 30

Describe an individual contract

Accepted Answer

ins plan issued directly to an individual & their dependents, employers & groups not eligible for these plans

Question 31

Determines which parents ins. is primary for a child, based on month & day of a calendar year

Accepted Answer

the birthday rule

Question 32

A record sheet used to record daily business transactions

Accepted Answer

daysheet

Question 33

Name some savings options with CDHP/Consumer Directed Health Plans

Accepted Answer

HSA/Healthcare Spending Account, HRS/Health Reimbursement Account, MSA/Medical Savings Account

Question 34

A service never covered within a health insurance policy

Accepted Answer

exclusion

Question 35

Written authorization by subscriber to ins carrier to pay benefits to provider not subscriber

Accepted Answer

assignment of benefits

Question 36

What 2 laws, when combined together are commonly referred to as the Affordable Care Act (ACA)?

Accepted Answer

Healthcare & Education Reconciliation Act 2010, Patient Protection & Affordable Care Act 2010, aka Obamacare

Question 37

What is a group contract?

Accepted Answer

ins plan where employer is policyholder, all enrolled employees are covered members, individual certificates issued to each insured member

Question 38

Types of funding options coupled with CDHPs

Accepted Answer

HSAs/Health Savings Account, FSAs/Flexible Spending Account, HRAs/Health Reimbursement Account, MSAs/Medical Savings Account

Question 39

Describe a CDHP

Accepted Answer

Patients design their own health plans based on their needs, coupled w/high deductible PPO & a tax advantage savings acct

Question 40

An amount of money that is usually paid monthly to keep a policy in force

Accepted Answer

premium

Basic Health Insurance MA105 EXAM 1

Questions 40

Basic Health Insurance MA105 EXAM 1

Questions 40