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Flashcards in Part 4 Deck (10)
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In the accounting system of the physician office, the account is categorized as "self-pay." How should the insurance analyst interpret this category?

A. The patient will pay deductibles and non covered charges
B. The physician, himself, or herself, will pick up the balance of the bill
C. The guarantor will pay the entire bill
D. The employer's self-issured healthcare insurance plan will cover the amount

The guarantor will pay the entire bill


A price list for the hospital that contains descriptions of goods and services, the prices, and any special codes that are required for billing.

A. Medically necessity
B. Advanced beneficiary notice
C. Chargemaster
D. Waiver



Group health insurance is available through employers and other organizations, and all or part of the premium costs are paid by employers. Employer-based group health_insurance_ __________.

A. Covers all employees, regardless of health status, and cannot be canceled if an employee becomes ill
B. Prohibits employer-limited plans options, such as a prescription drug plan that covers a certain list of medications, which is called formulary
C. Excludes COBRA continuation coverage upon employee resignation or another qualifying event and lasts for 18to 36 months, depending on the employee's situation
D. Requires exclusions for pre-existing conditions, which means the payer excludes all employees from coverage for pre-existing conditions

Covers all employees, regardless of health status, and cannot be canceled if an employee becomes ill


TRUE/FALSE: Medicare Part D enrollment is automatic



Which of the following services has the highest likelihood of being a "covered services"?

A. Medically necessary
B. Medically Unnecessary
C. Cosmetic
D. Preexisting condition

Medically necessary


Any procedure or service reported on the claim that is not included on the master benefit list is a non covered benefit and will result in claims _________.

A. Approval
B. Denial
C. Submission
D. Payment



In 2020, Medicare Part B patients pay an annual deductible of

A. $198
B. $147
C. $114
D. $135



If a patient has Blue cross/blue shield through their spouse's employer, but is also a Medicare beneficiary, Medicare would be:

A. Primary payer, but only as long as the patient was 65 for over
B. Secondary payer
C. Not billed in this case at all
D. Primary payer

Secondary payer


Which is the electronic or manual transmission of claims data to payer or clearinghouses
for processing?

A. Claims processing
B. Claims payment
C. Claims Submission
D. Claims Adjudication

Claims Submission


In regards to healthcare insurance, the percentage that the guarantor pays is called the

A. deductible
B. copayment
C. contractual disallowance
d. coinsurance