Deck 27: Health Insurance

Question 1

Under the birthday rule,if the parents' divorce and retain their plans,the parent with _____ is primary.

A) the greater income
B) the plan in effect the longest
C) custody
D) the parent with the plan that provides the best coverage

Answer 1

custody

Question 2

Part ___ of Medicare is for payment of medical expenses such as office visits and X-ray and laboratory services.

A) A
B) B
C) C
D) D

Answer 2

B

Question 3

Which type of HMO is composed of providers who practice in their own individual offices and retain their own staff and operations?

A) staff model
B) group model
C) PPO
D) independent practice association

Answer 3

independent practice association

Question 4

Part ___ of Medicare was created to provide coverage for both generic and brand name drugs.

A) A
B) B
C) C
D) D

Question 5

Health insurance offered by private companies to persons eligible for Medicare benefits and specifically designed to supplement such benefits is called:

A) Medigap
B) Medicaid
C) TRICARE
D) CHAMPVA

Question 6

A provider may not charge a patient for:

A) the part of the deductible that has not been met
B) an amount reimbursed after accepting assignment
C) any coinsurance that is due
D) a service not covered by the patient's insurance

Question 7

Match each health insurance term with its definition.
Specified amount that the insured must pay toward the charge for professional services rendered at the time of service

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 8

When a provider does not accept assignment from Medicare,the most that can be charged to the patient is ___ percent of the Medicare-approved amount.

A) 85
B) 100
C) 115
D) 150

Question 9

Physicians who treat patients under workers' compensation plans are usually required to register with the state Workers' Compensation Board:

A) anytime they need to file a claim
B) only once,unless they move or change the name of the medical practice
C) on an annual basis
D) every 5 years

Question 10

When patients without health insurance are seen in the medical practice,they are classified as ____ patients.

A) pro bono
B) self-pay
C) reimbursement
D) TRICARE

Question 11

Once a patient is ready to leave the hospital,____ is used to ensure that the patient is being discharged to the most appropriate setting.

A) discharge planning
B) capitation
C) utilization review
D) diagnostic planning

Question 12

Ideally,a person in the medical office is designated the ____ and is expected to submit accurate claims in compliance with the many rules and regulations.

A) medical coder
B) claims filer
C) update technician
D) seminar specialist

Question 13

Blue Cross was originally set up to pay for:

A) physicians' services
B) hospital expenses
C) prescription medications
D) preventive health care

Question 14

Because a primary care physician (PCP)in an HMO makes referrals and approves additional care if needed,he or she is known as the:

A) gatekeeper
B) patient advocate
C) specialist
D) care manager

Question 15

The only practitioners that can currently bill Medicare with the hard-copy CMS-1500s are businesses with:

A) less than 10 full-time employees,including physicians
B) more than 20 full-time employees,including physicians
C) less than 10 full-time employees,excluding physicians
D) more than 20 full-time employees,excluding physicians

Question 16

In a(n)_____ plan,patients are able to see specialists without having to obtain referrals from another physician.

A) preferred provider organization (PPO)
B) health maintenance organization (HMO)
C) independent practice association (IPA)
D) indemnity-type insurance

Question 17

Under workers' compensation,a patient who has an industrial injury is billed:

A) for 20 percent of the cost of treatment
B) for 80 percent of the cost of treatment
C) for the entire cost of treatment
D) if treatment was given without authorization

Question 18

When a patient arrives at the medical office,you should copy (or scan)_____ of the insurance card(s).

A) only the front
B) only the back
C) both sides
D) neither side

Question 19

The term ____ refers to the discovery of the maximum amount of money that a carrier will pay for primary surgery,consultation services,and so on.

A) precertification
B) pretreatment
C) preauthorization
D) predetermination

Question 20

Medicare pays ____ of the approved medical bill amount once the deductible is satisfied.

A) 20
B) 60
C) 70
D) 80

Question 21

Match each health insurance term with its definition.
Method of controlling health care costs by reviewing services to be provided to members of a plan to determine the appropriateness and medical necessity of the care prior to the delivery of the care

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 22

Match each health insurance term with its definition.
Predetermined amount that the insured must pay each year before the insurance company will pay for an accident or illness

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 23

Match each health insurance term with its definition.
Insurance offered to all employees by the employer

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 24

Match each health insurance term with its definition.
Commercial plan in which the insurance company or group reimburses providers or beneficiaries for services

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 25

Match each health insurance term with its definition.
Condition that existed before the insured's policy was issued

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 26

Match each health insurance term with its definition.
A form of insurance providing wage replacement and medical benefits to employees who are injured on the job or who have developed work-related disorders,disabilities,or illnesses

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 27

Match each health insurance term with its definition.
Group insurance that entitles members to services provided by participating hospitals,clinics,and providers

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 28

Match each health insurance term with its definition.
Authorization,by signature of the patient,for payment to be paid directly by the patient's insurance to the provider for services

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 29

Match each health insurance term with its definition.
Established to aid dependents of active service personnel,retired service personnel and their dependents,and dependents of service personnel who died on active duty,with a supplement for medical care in military or Public Health Service facilities

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 30

Match each health insurance term with its definition.
Numeric values assigned to payment components of the resource-based relative value scale (RBRVS)

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 31

Match each health insurance term with its definition.
Geographic area served by an insurance carrier

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 32

Match each health insurance term with its definition.
Health care delivery system that combines the delivery of health care and payment of the services

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 33

Match each health insurance term with its definition.
Joint funding program by federal and state governments for the medical care of low-income patients on public assistance

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 34

Match each health insurance term with its definition.
Date when an insurance policy goes into effect

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 35

Match each health insurance term with its definition.
When a health care provider is paid a fixed amount per member per month for each patient who is a member of a particular insurance organization,whether or not services were provided

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 36

Match each health insurance term with its definition.
Approval obtained before the patient is admitted to the hospital or receives specified outpatient or in-office procedures

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 37

Match each health insurance term with its definition.
Procedures used by insurers to avoid duplication of payment on claims when a patient has more than one policy

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 38

Match each health insurance term with its definition.
Insurance purchased by an individual or family who does not have access to group health insurance

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 39

Match each health insurance term with its definition.
Person who is insured;an insurance policyholder

A)managed care
B)Medicaid
C)precertification
D)preexisting condition
E)service area
F)subscriber
G)individual insurance
H)indemnity plan
I)utilization management (review)
J)workers' compensation

Question 40

Match each health insurance term with its definition.
Established for the spouses and dependent children of veterans who have total,permanent,service-connected disabilities

A)assignment of benefits
B)TRICARE
C)CHAMPVA
D)coordination of benefits (COB)
E)co-payment
F)deductible
G)effective date
H)capitation
I)group insurance
J)health maintenance organization (HMO)

Question 41

Match each health insurance term with its definition.
Procedures used by insurers to avoid duplication of payment on claims when the patient has more than one policy

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 42

​The traditional type of insurance that once covered the cost of medical care is fast becoming extinct.Even though traditional private insurance is fading,there are still individuals who choose to pay high premiums so that they have the flexibility to seek medical care from health care professionals of their choice.This type of care is still very attractive to many individuals who want the freedom to seek care from any provider and not worry about whether they are remaining in their network,and is known as:

A) ​fee-for-service
B) ​preferred provider selection
C) ​primary care insurance
D) ​none of the above

Question 43

Match each health insurance term with its definition.
Term for an insurance company that reimburses for health care services

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 44

Match each health insurance term with its definition.
Patient's eligibility for benefits

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 45

​Match the following terms with its definition.
Refers to the discovery of the maximum amount of money the carrier will pay for primary surgery,consultation service,postoperative care,and so on

A)precertification
B)​preauthorization
C)​predetermination

Question 46

​Match the following terms with its definition.
​Seeking approval for a treatment (surgery,hospitalization,diagnostic test)under the patient's insurance contract

A)precertification
B)​preauthorization
C)​predetermination

Question 47

​Match the following terms with its definition.
​Relates not only to whether the services are covered but also whether the proposed treatment is medically necessary

A)precertification
B)​preauthorization
C)​predetermination

Question 48

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

A) ​indemnity-type insurance
B) ​health maintenance organization
C) ​preferred provider organization
D) ​all require a referral to see a specialist or another provider

Question 49

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

A) ​Patient must first see his or her primary care provider (PCP).
B) ​The PCP must generate a referral in order for the patient to see a specialist.
C) ​The provider (or MA)must obtain verification of eligibility for services.
D) ​All of the above.

Question 50

Match each health insurance term with its definition.
Provider who has contracted with an insurer and accepts whatever the insurance pays as payment in full

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 51

​The following health care model is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into "what patients want it to be," and leads to higher quality and lower costs and can improve patients' and providers' experience of care:

A) ​Accountable Care Organization (ACO)
B) ​Health Maintenance Organization (HMO)
C) ​Patient-Centered Medical Home (PCMH)
D) ​all of the above

Question 52

Match each health insurance term with its definition.
Required by Medicare when a service is provided to a beneficiary who is either not covered or the provider is unsure of coverage

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 53

​Which of the following would be considered a step or steps to verify insurance coverage and eligibility?

A) ​Determine if the insurance is managed care.
B) ​Access the website for the patient's insurance carrier (or use the EHR application with electronic eligibility features).
C) ​Complete the required fields,verifying you have the correct patient information and that the patient is eligible for services.
D) ​All of the above are necessary steps.

Question 54

Match each health insurance term with its definition.
Payments made to an insured person to help replace income lost through inability to work because of an insured disability

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 55

​Which of the following would be considered a step or steps to obtain precertification or preauthorization (predetermination)for a procedure for a patient with a managed care plan?

A) ​Determine if precertification or preauthorization is required.
B) Locate the form on the insurance company website (or call the insurance company if you cannot locate or have questions).
C) ​Complete the form correctly,fax to the insurance company (or send electronic authorization request).
D) ​All of the above are necessary steps.

Question 56

​Which of the following statement(s)is/are true?

A) ​When a patient is covered by an indemnity-type plan,most practices will file the claim with the insurance company on the patient's behalf.
B) ​When a patient is covered by an HMO,the provider's office files the claim with the insurance company on the patient's behalf.
C) ​Providers and suppliers are not required to file the Medicare claim if the service is not covered by Medicare unless the service is provided on an assigned basis and the beneficiary requests the provider to submit the claim
D) ​All of the above

Question 57

Match each health insurance term with its definition.
List of predetermined payment amounts for professional services provided to patients

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 58

​Which of the following are considered third-party (insurance)plans?

A) ​Group health plans
B) ​Medicare
C) ​Court-ordered health coverage
D) ​All of the above

Question 59

Match each health insurance term with its definition.
Insurance company that intervenes to pay hospital or medical bills per contract with the doctor or patient

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 60

Match each health insurance term with its definition.
When health care providers inform patients of charges before the services are performed

A)advance beneficiary notice (ABN)
B)carrier
C)coordination of benefits (COB)
D)fee disclosure
E)fee schedule
F)loss-of-income benefits
G)participating provider
H)patient status
I)relative value units
J)third-party payer

Question 61

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
​Preventive care is not subject to the deductible

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 62

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
​The employer owns the money in this account,and it might not be portable when the employee leaves the company

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 63

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
​Referred to as a cafeteria plan

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 64

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
​Has a high deductible and must be paired with a qualified health plan

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 65

​Match the Part of Medicare to its definition.Note: Answers may be used more than once.
​Also known as Medicare Advantage

A)​Part A
B)​Part B
C)​Part C
D)​Part D

Question 66

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
An employer can contribute,but an employee cannot

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 67

​Match the Part of Medicare to its definition.Note: Answers may be used more than once.
​Provide coverage for both generic and brand-name drugs

A)​Part A
B)​Part B
C)​Part C
D)​Part D

Question 68

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
​The amount can be rolled over from one year to the next

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 69

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
​Any amount not used in a given year remains in the account and continues to gain interest

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 70

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
​A tax-sheltered savings account that can be used to pay for medical expenses

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 71

​A nonprofit organization created to improve patient care quality and health plan performance in partnership with managed care plans,purchasers,consumers,and the public sector is known as:

A) the Affordable Care Act Compliance department
B) ​the Health Insurance Portability and Protection Act (HIPAA)
C) ​the Health Maintenance Organization (HMO)
D) ​the National Committee for Quality Assurance (NCQA)

Question 72

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
​A "use it or lose it" type plan

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 73

​Match the Part of Medicare to its definition.Note: Answers may be used more than once.
Enables beneficiaries to select a managed care plan as their primary coverage

A)​Part A
B)​Part B
C)​Part C
D)​Part D

Question 74

​Medicare will ______ pay for services or supplies considered medically reasonable and necessary for the diagnosis given

A) ​only
B) ​not
C) ​sometimes
D) ​none of the above

Question 75

​The standard claim form designed by the Centers for Medicare and Medicaid Services to submit provider services for third-party (insurance companies)payment is known as:

A) ​the Affordable Care Act
B) ​the CMS-1500
C) ​the coordination of benefits
D) ​the fee disclosure

Question 76

​Match the Part of Medicare to its definition.Note: Answers may be used more than once.
​A benefit that was introduced for beneficiaries as of January 1,2005,was the Initial Preventive Physical Exam,otherwise known as the Welcome to Medicare visit

A)​Part A
B)​Part B
C)​Part C
D)​Part D

Question 77

​Match the type of consumer-driven health plan to its definition.Note: Answers can be used more than once.
​The plan is usually funded by the employee with pretax dollars

A)​health savings account
B)​health reimbursement arrangement
C)​flexible spending arrangement

Question 78

​Match the Part of Medicare to its definition.Note: Answers may be used more than once.
​For payment of other medical expenses,including office visits,X-ray and laboratory services,and the services of a provider in or out of the hospital

A)​Part A
B)​Part B
C)​Part C
D)​Part D

Question 79

​Match the Part of Medicare to its definition.Note: Answers may be used more than once.
​For hospital coverage

A)​Part A
B)​Part B
C)​Part C
D)​Part D

Question 80

​In some cases,the Medicare insurance carrier automatically sends the amount not covered on to a private secondary insurance carrier (known as a _______________________),which may pay the deductible and the 20 percent not covered,eliminating the need to fill out additional forms.

A) ​universal claim
B) ​secondary claim
C) ​crossover claim
D) ​none of the above