🌟Medical Insurance Management- CH 16

Under which type of managed care plan will the cost of services be covered only if the patient receives care from a participating physician>

HMO

When does the “birthday rule” help determine the primary insurance plan?

When a child is covered by both parents

Which type of insurance does not require a referral for patient care and specialists?

preferred provider organization (PPO)

What is used to verify eligibility for a TRICARE patient?

DEERS

What is the terms for an illness or injury that makes the insured unable to perform the major duties of their specific occupation?

Total disability

What is the term for periodic payments made to keep an insurance policy in force?

Premiums

Under which type of managed care plan can enrollees obtain services from nonparticipating physicians and pay a higher deductible and co-payment

PPO

What does the Department of Defense offer to supplement Medicare?

TRICARE for life

Who is the third-party payer?

The entity that bears the cost of medical services, such as insurance company, government programs, or managed care plans

What is the process of finding out the maximum dollar amount that an insurance company will pay for a particular service or procedure?

Predetermination

What is the requirement to generate a referral for a patient with a managed care insurance plan?

All of the responses are correct

If an established patient is also being seen for a worker’s compensation disability claim, which action is correct by the medical assistant?

Create two separate medical records and accounts on the patient

What kind of patient has both Medicare and Medicaid?

Medi/Medi case

A voluntary prescription drug coverage plan falls under which part of the Medicare program?

Part D

What is a “HDHP”

Insurance health plan with a high deductible

Where is a state disability insurance offered?

Only in five states and Puerto Rico

To contain costs and prosecute cases of Medicare and Medicaid fraud, what law did the government pass?

Civil Monetary Penalties Law

Hospital insurance benefits are provided under which part of the Medicare program?

Part A

Which federal legislation requires that employers offer extended group health insurance benefits to employees and dependents affected by job loss or other life events?

COBRA

Precertification of services must be obtained before the patient is admitted to the hospital or receives specified outpatient or in office procedures T/F

True

What kind of legally enforceable document is an insurance policy?

Contract

Identify managed care requirements for patient referral- all of the above

All of the above

What must a group contract include to allow someone who leaves the organization to maintain the same or lesser coverage under an individual policy?

Conversion privilege

What kind of Medicare coverage applies to services in a physician’s office?

Part B

What is the term for an injury or illness that occurred before the issuance of a health insurance policy?

Preexisting condition

What is the process of finding out if a service or procedure is covered under a patient’s insurance policy?

Precertification

What information must be copied from a patient’s insurance card?

The front and back of the card

What form is completed and submitted to a third-party payer for reimbursement?

CMS-1500 claim

Precertification

Seeking approval for a treatment (surgery, hospitalization, and diagnostic test) under the patient’s insurance contract

Preauthorization

Relates not only to whether the services are covered but also to whether the proposed treatment is medically necessary

Predetermination

Refers to the discovery of the maximum amount of money the carrier will pay for primary surgery, consultation service, postoperative care, and so on