MED 131: Unit 1-4 Test

Which Medicare plan covers prescription medications?

Part D

What percent of the allowable fee does Medicare pay the healthcare provider after the annual deductible is met?

80%

A small fee that is collected at the time of service is called a(n) ___.

copayment

The fixed dollar amount a subscriber must pay or "meet" each year before the insurer begins to cover expenses is the ________

deductible

The person whose name the insurance is carried under is called the ________

subscriber

Patients who belong to a managed care health plan, such as an HMO, are responsible for a small per-visit fee collected either prior to seeing the practitioner or at the time the patient is leaving the office. This fee is commonly called a(n) ________

copayment

What is the authorization called that directs an insurance carrier to pay the medical provider or the medical practice directly?

assignment of benefits

Patients under the age of 65 who are blind or widowed or who have serious long-term disabilities, such as ________, may be entitled to Medicare.

kidney failure

Eligibility for Medicaid is ________.

based on the patient's reported income and assets from the previous month

Of the federal programs providing healthcare, the largest is ___, which provides health insurance for citizens aged 65 and older.

Medicare

Billing the patient for the difference between a higher usual fee and a lower allowed charge is called ___ billing.

balance

Which of the following groups are not covered by TRICARE or CHAMPVA?

non-military government employees

HMO stands for:

Health Maintenance Organization.

Which of the following types of insurance covers injuries that are caused by the insured or that occurred on the insured's property?

liability

Who provides funds to the Medicaid program?

The federal and state governments

When a provider agrees to accept assignment for a Medicare patient, this means the provider ________

will accept the amount of money Medicare pays as payment in full

The request for approval for payment from a third-party payer prior to a procedure is the ________.

preauthorization

The usual fees that are listed on the medical office's fee schedule are fees ________.

charged to most of their patients most of the time under typical conditions

Medicare covers those who are:

65 and older and some persons under 65 who qualify.

The resource-based relative value scale (RBRVS) is a payment system used by:

Medicare

When the insured person pays an annual cost for healthcare insurance, it is called a ________

premium

Workers' compensation covers those who:

get hurt on the job.

To be covered under Medicare Part B, patients must ________

enroll, because coverage is not automatic

The process of deciding the amount of money that will be paid by a third-party payer for a procedure is ________

predetermination

Under a contracted or fixed prepayment called ___, providers are paid a fixed amount of money to provide needed care.

capitation

Those persons under 65 that qualify for Medicare are:

blind or have serious long-term disabilities.

The ___ is a fixed amount that must be paid by the policyholder each year before a third-party payer begins to cover medical expenses.

deductible

The health plan that pays for medical services is known as a ___ payer.

third-party

Which statement is true about TRICARE?

TRICARE for Life acts as a secondary payer to Medicare.

Which of the following is a characteristic of Medicaid?

It is a health cost assistance program.

The list of drugs approved by an insurance company is called a(n) ________.

formulary

Which of the following plans covers surviving spouses and dependent children of veterans who died in the line of duty or as a result of a service-connected disability?

CHAMPVA

Which of the following must be verbally discussed with a Medicare beneficiary to enable the beneficiary to consider options and make informed choices?

ABN

A fixed-dollar amount the subscriber must pay, or “meet,” each year before the insurer begins to cover expenses is the:

deductible

The patient's portion of medical charges can be termed

copayment or coinsurance

Most specialists are paid by MCOs using

negotiated per-service fees

The national health insurance plan for Americans age 65 and older is

Medicare

he appropriate definition for a Medicaid plan is

Health benefit plan

Which of the following is not performed by the medical practice when preparing a healthcare claim for payment and reviewing the insurance payment?

Submitting the employer's first report of illness or injury

Why is it important that each procedure on the CMS-1500 be matched with a diagnosis code?

It proves medical necessity for the procedure

Which of the following is the most common method for medical practices to submit electronic medical claims to third-party payers?

Clearinghouse

Which of the following documents provides information regarding the payer's payment (or denial) of charges received?

RA or EOB

Insurance carriers perform a review for medical ________blank on each claim to determine whether the treatment is needed for the diagnosis listed.

necessity

The electronic claim transaction preferred by Medicare is the X12 837 Health Care Claim, commonly referred to as the " ___ claim.”

HIPAA

You should track claims sent to the insurance carrier because:

you need a record of claims sent so you can follow up.

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