Health Insurance Plans
HMO members must choose a ___.
PCP
Which of the following statements regarding copayments is NOT true?
Many insurance plans require the policyholder to pay a copayment for medical services rendered.
Most health insurance plans require a copayment for wellness exams.
Copayment amounts are typically disclosed to the policyholder before they select a plan.
A copayment is a fixed amount that an individual must pay for a specific medical service or medication.
B. Most health insurance plans require a copayment for wellness exam.
A person who has no income or falls below a certain percentage of the federal poverty level is usually eligible for _________.
Medicaid
Patient demographics include a patient’s _____.
C Phone Number
Amari is covered by two insurance plans. Which statement regarding the coordination of benefits is true?
The primary insurance plan must be billed first.
The secondary insurance plan must be billed first.
Following coordination of benefits, reimbursement may exceed the initial/actual cost of services billed for.
Both insurances must be billed at the same time.
A. The primary insurance plan must be billed first.
Medicare Part ___, also known as Medicare Advantage, is offered by private companies as an alternative to Original Medicare.
Part C
Melinda goes to her primary care physician for an annual physical exam. She has a $500 deductible and an 80/20 coinsurance plan. Her health insurance plan pays 100% of preventative-care costs, which are not applied to the yearly deductible. The charge for her visit is $750. How much will Melinda have to pay?
$0
A person who was diagnosed with amyotrophic lateral sclerosis (ALS) is eligible for this federally funded program.
Medicare
Verification of insurance in real time is done by ____.
EDI
The birthday rule is determined by the_____.
Parents or guardian's birth date and birth month.
A person who was diagnosed with ALS, or Lou Gehrig’s disease, is eligible for which federally funded program?
Medicare
Shreya has paid $250 toward her $500 deductible. She has an 80/20 plan. She sees her primary care physician for hypertension. The total allowed charge is $150. What is her payment responsibility?
$150
Coverage that is added to homeowners' insurance to pay for the medical expenses of someone who gets injured on the property is called______________________.
Medical Payments Coverage
A(n) _____ needs to be issued to a Medicare beneficiary when a service most likely will not be covered by insurance.
ABN
__________ is generally known as the payer of last resort.
Medicaid
Third-party liability (TPL) is a federal regulation that requires states to take measures to _____.
increase claim payments by the payer of last resort
identify other third-party liability before claims are paid
ensure HIPAA compliance in claims submission
increase clean claims submitted to third-party payers
B. Identify other third-party liability before claims are paid.
Jessica sees a specialist for carpal tunnel syndrome. The total allowable charge is $150. She has met $400 of her $500 deductible and has an 80/20 coinsurance plan. How much is Jessica responsible for?
$110
Which of the following describes Medicare Part C?
It is free for most people who are eligible for Medicare.
It is often referred to as Original Medicare.
It is offered by private companies as an alternative to Original Medicare.
It is offered only to Medicare eligible individuals under age 65 with certain disabilities.
C. It is offered by private companies as an alternative to Original Medicare.
The ______________ should contact the insurance plan to obtain preauthorization for a referral.
Referring Provider
Medicaid, by law, will only pay claims that have exhausted all other sources of coverage. This regulation is known as _____________________.
Third-Party Liability
Durable medical equipment (DME), such as walkers and wheelchairs, is covered under Medicare Part ___.
Part B
For his employer-sponsored health insurance plan, Marco is responsible for paying $798 a year, which is divided evenly by the number of pay periods in the year and automatically deducted from each paycheck. Marco is paid monthly. How much will be taken out of each monthly paycheck?
$66.50
$798 a year divided by 12 = $66.50
Which of the following is NOT a Medicare Part B ABN notifier?
Suppliers of Medical Products
Hospice
Independent Laboratories
Outpatient Facilities
B. Hospice
Which of the following statements regarding EDI is true?
C It is an electronic method of communicating standard transactions.
In certain circumstances, the _____ can decide which insurance will be billed first when a dependent has two insurance plans.
Court