Deck 6: Traditional Fee For Service/Private Plans

Question 1

Many self-insured groups hire a specific type of organization to manage and pay claims called:

A) third-party administrators (TPAs).
B) administrative services organizations (ASOs).
C) employee retirement services administrators (ERSAs).
D) both a and b

Answer 1

both a and b

Question 2

The type of provider that enters into a contractual agreement with the carrier and agrees to follow the payer's specific rules involving claims and payment in return for certain advantages is called a ________ provider.

A) PAR
B) non-PAR
C) contractual
D) supplemental

Answer 2

PAR

Question 3

Insurance companies are referred to as _____ payers.

A) first-party
B) second-party
C) third-party
D) primary

Answer 3

third-party

Question 4

One of the provisions of the Affordable Care Act was that most insurance plans must eliminate

A) periodic premiums.
B) cost sharing.
C) payment for preventive care .
D) lifetime insurance caps.

Question 5

The kind of health insurance paid for by a business entity other than the government is called:

A) managed care.
B) employer-sponsored care.
C) commercial health insurance.
D) medical savings accounts.

Question 6

The "traditional" type of health insurance policy whereby the insurance company pays all or a portion of the fees for the services provided to the individual covered by the policy is called:

A) fee-for-service (FFS).
B) managed care.
C) health maintenance.
D) usual, customary, and reasonable.

Question 7

The plan types within managed care plans include all of the following,except:

A) health savings accounts.
B) point-of-service (POS) plans.
C) preferred provider organizations (PPOs).
D) health maintenance organizations (HMOs).

Question 8

Blue Cross Blue Shield underwrites many different plan types;identify which of the following plan is not one of them:

A) BCBS Worldwide Program
B) Federal Employee Program (FEP)
C) TRICARE Military Program
D) FEHB Program

Question 9

The two basic categories of health insurance are FFS and:

A) managed care.
B) group insurance.
C) individual policies.
D) health savings accounts.

Question 10

Today,the "Blue System" is the largest single processor of Medicare Part A claims,which is commonly referred to as a:

A) claims processor.
B) fiscal intermediary.
C) carrier direct payer.
D) commercial contractor.

Question 11

The time limit for filing claims:

A) is 60 days.
B) is 120 days.
C) is 1 year.
D) varies among payers.

Question 12

Blue Cross and Blue Shield claims must typically be filed within _____ following the last date of service provided to the patient.

A) 90 days
B) 365 days
C) 2 years
D) 5 years

Question 13

The Affordable Care Act requires that plans sold to individuals and small businesses provide a minimum package of services in 10 categories called

A) The 10 basic benefits package
B) Essential health benefits
C) Comprehensive groups
D) Medically necessary assistance

Question 14

Prior to submitting a claim,the healthcare professional should:

A) assume timely filing length is at least 1 year.
B) assume timely filing is the same for all carriers.
C) follow provider guidelines.
D) follow payer guidelines.

Question 15

Many Americans obtain health insurance owing to their employment through what is commonly referred to as:

A) COBRA.
B) Medicare.
C) group insurance.
D) primary coverage.

Question 16

Submitting claims to third-party carriers within the time limits set forth in the payer's guidelines is referred to as _____ filing.

A) electronic
B) specific
C) timely
D) contractual

Question 17

The federal act that sets minimum standards for pension plans for private industry is:

A) ERISA.
B) COBRA.
C) CHAMPVA.
D) EMTALA.

Question 18

Another term for "insurance cap" is:

A) in-between coverage.
B) deductible.
C) stop loss.
D) long-term care.

Question 19

A document prepared by the carrier that gives details of how a claim was adjudicated is called a/an:

A) secondary claim.
B) claim explanation.
C) explanation of benefits.
D) adjudication notice.

Question 20

The earliest and probably best known commercial insurer in this country is:

A) Medicare.
B) Medicaid.
C) Metropolitan Life.
D) Blue Cross and Blue Shield.

Question 21

A set of government-regulated and standardized healthcare plans from which individuals may purchase health insurance eligible for federal funding are:

A) consumer directed health plans.
B) self-funded groups.
C) health insurance exchanges.
D) Federal Employees Health Benefits (FEHB) Program.

Question 22

Identify the recent federal act that amended HIPAA's "credible coverage" rule.

A) Employee Retirement Income Security Act
B) The Patient Protection and Affordable Care Act
C) Federal Employees Health Benefits Act
D) Pre-Existing Condition Insurance Act

Question 23

If the health insurance professional needs to know a particular carrier's rules for completing the CMS-1500,the best thing to do is to:

Question 24

Within these two broad categories,what are the four basic types of health insurance?

Question 25

To make sure electronic claims have been received by the payer (or clearinghouse),the health insurance professional should review the ________________,a report that the carrier normally sends after each electronic transmission.

Question 26

Name the type of managed care plan that combines characteristics of both the HMO and the PPO.

Question 27

A system of payments established by the Centers for Medicare and Medicaid Services (CMS)to reimburse healthcare providers for treating Medicare patients.

Question 28

Name the three out-of-pocket costs in a fee-for-service plan.

Question 29

In addition to the premium,an out-of-pocket amount that usually must be paid before insurance payments begin is called the ___________.

Question 30

The legislation that includes a mandate that insurance companies must cover certain preventive services for those who purchased or joined a new plan on or after September 23,2010,without charging out-of-pocket costs,is:

A) ERISA.
B) COBRA.
C) Health Insurance Privacy and Portability Act.
D) Patient Protection and Affordable Care Act.

Question 31

If a claim is denied as "untimely,":

A) benefits will always be denied.
B) an appeal can be submitted in certain cases.
C) the patient is responsible for the entire bill.
D) the provider must always cancel the charges for the encounter.

Question 32

Identify the term that refers to the commonly charged or prevailing fees for health services within a geographic area.

Question 33

A document prepared by the carrier that gives details of how the claim was adjudicated is called a/an ________________.

Question 34

Any organization (e.g.,Medicare or commercial insurance company)that provides payment for specified services covered under a health insurance plan is referred to as a _______________________.

Question 35

The Affordable Care Act states that by 2014,everyone in the United States will be required to purchase a comprehensive set of healthcare benefits,which is referred to as:

A) minimum essential coverage.
B) major medical coverage.
C) essential benefits package.
D) a or c

Question 36

Name the two basic categories of health insurance.

Question 37

A/An ___________________ allows payments to be posted to patients' accounts automatically,eliminating manual posting of claim payments to both electronic and paper claims.

Question 38

An organization that determines payment for Part B-covered items and provider services is now more commonly called a ______________________.

Question 39

________________ is designed specifically to provide coverage for some of the costs that Medicare does not pay,such as Medicare's deductible and coinsurance amounts.

Question 40

Prior to the passage of the Affordable Care Act,a _____________ was the most common way to provide individuals access to health insurance if the person had been denied coverage because of a preexisting condition and had been without coverage for a period of at least 6 months.

Question 41

Providers who do not contract with a particular insurance carrier are called nonPARs.

Question 42

Explain what Blue Cross and Blue Shield means by "timely filing."

Question 43

One kind of commercial insurance that the government does pay is the FEHB program,which is healthcare coverage for its own civilian employees.

Question 44

Medicare supplemental insurance is intended to cover some costs that Medicare does not pay.

Question 45

Employers cannot be "self-insured."

Question 46

When you see a suitcase emblem on a Blue Cross and Blue Shield card,it indicates that the patient is a government employee.

Question 47

Blue Cross and Blue Shield policies are strictly fee-for-service plans.

Question 48

A PAR provider agrees to accept the amount paid by the insurance carrier as "payment in full" after both the deductible and copayment have been met.

Question 49

Commercial carriers must furnish their own specific insurance claim form and cannot use the CMS-1500.

Question 50

Explain the term "reasonable and customary."

Question 51

What is "self-insurance?"

Question 52

What functions does a TPA perform?

Question 53

Explain the BlueCard Program.

Question 54

Explain the function of a fiscal intermediary/Medicare administrative contractor.

Question 55

Eliminating a certain specialty of health services (e.g.,vision or dental care)from coverage is called a "carve out."

Question 56

Define "commercial" health insurance.

Question 57

The yearly deductible (out-of-pocket payment)is the same for all commercial carriers.

Question 58

Under the Affordable Care Act,insurance companies must cover certain preventive services without charging out-of-pocket costs.Name three.

Question 59

In an FFS health plan,members typically pay a certain percentage of covered charges,called coinsurance.

Question 60

How would the health insurance professional identify members of the BlueCard Program?

Question 61

Medicare fiscal intermediaries (FIs)and carriers are now more commonly referred to as Medicare administrative contractors (MACs).

Question 62

When switching jobs,HIPAA guarantees the same level of benefits,deductibles,and claim limits the individual might have had under the former employer's health plan.

Question 63

Most healthcare providers in the United States accept Blue Cross and Blue Shield patients.

Question 64

Under the Affordable Care Act,no annual dollar limits are allowed on most covered benefits beginning January 1,2014.

Question 65

Consumer directed health plans (CDHPs)often involve pairing a high deductible PPO plan with a tax-advantaged account,such as a health savings account (HSA).

Question 66

A self-insured health plan can only be offered by the federal government.

Question 67

In the case of "dual coverage," the primary carrier's explanation of benefits (EOB)should typically accompany the claim sent to the secondary insurer.

Question 68

Blue Cross and Blue Shield organizations are governed at the national level.

Question 69

Fee-for-service plans offer the most choices of healthcare providers.

Question 70

Blue Cross covers inpatient hospital expenses;Blue Shield applies to physician and other healthcare provider's services.

Question 71

HIPAA-AS sets standards for the electronic transmission of healthcare data and to protect the privacy of individually identifiable healthcare information.

Question 72

Self-insured plans usually do not have to conform to traditional laws governing insurance,because they are technically not considered insurance companies.

Question 73

Claims completion guidelines are the same for all government and commercial carriers.

Question 74

One of the provisions of healthcare reform was the removal of lifetime caps on insurance.