| Chapter 3&4 Review Category 1 | Chapter 3&4 Review Category 2 | Chapter 3&4 Review Category 3 | Chapter 3&4 Review Category 4 | Chapter 3&4 Review Category 5 |
| 5 | 5 | 5 | 5 | 5 |
| 10 | 10 | 10 | 10 | 10 |
| 15 | 15 | 15 | 15 | 15 |
| 20 | 20 | 20 | 20 | 20 |
| 25 | 25 | 25 | 25 | 25 |
| Final Question | ||||
A policyholder or __________ is the person in whose name the insurance policy is issued.
A policyholder or __________ is the person in whose name the insurance policy is issued.
beneficiary
Which program resulted from the Balanced Budget Act of 1997 (BBA) and requires that quality assurance activities are performed to improve the functioning of Medicare Advantage (Medicare Part C) organizations?
Which program resulted from the Balanced Budget Act of 1997 (BBA) and requires that quality assurance activities are performed to improve the functioning of Medicare Advantage (Medicare Part C) organizations?
quality assessment and performance improvement (QAPI)
Secondary insurance is the insurance plan that is billed after the primary insurance plan has paid its contracted amount and the provider's office has received a(n) __________ from the primary payer.
Secondary insurance is the insurance plan that is billed after the primary insurance plan has paid its contracted amount and the provider's office has received a(n) __________ from the primary payer.
remittance advice
Which the fixed amount the patient pays each time he or she receives health care services?
Which the fixed amount the patient pays each time he or she receives health care services?
copayment
A managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee is called a(n) __________.
A managed care network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee is called a(n) __________.
point-of-service plan
A competitive medical plan (CMP) is an HMO that meets __________ eligibility requirements for a Medicare risk contract but is not licensed as a __________ qualified plan.
A competitive medical plan (CMP) is an HMO that meets __________ eligibility requirements for a Medicare risk contract but is not licensed as a __________ qualified plan.
federal; federally
Some managed care plans contract out utilization management services to a utilization review organization (URO), which is an entity that __________.
Some managed care plans contract out utilization management services to a utilization review organization (URO), which is an entity that __________.
establishes a utilization management program and performs external utilization review services
Which is usually offered either by a single insurance plan or as a joint venture among two or more insurance payers and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans?
Which is usually offered either by a single insurance plan or as a joint venture among two or more insurance payers and provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans?
triple option plan
Which is the assignment of lower-level codes than documented in the record?
Which is the assignment of lower-level codes than documented in the record?
downcoding
Which is a private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases the data to the public for consideration when selecting a managed care plan?
Which is a private, not-for-profit organization that assesses the quality of managed care plans in the United States and releases the data to the public for consideration when selecting a managed care plan?
National Committee for Quality Assurance
Medicare and many states prohibit managed care contracts from containing __________, which prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.
Medicare and many states prohibit managed care contracts from containing __________, which prevent providers from discussing all treatment options with patients, whether or not the plan would provide reimbursement for services.
gag clauses
Triple option plans are intended to prevent the problem of covering members who are sicker than the general population, which is called __________ selection.
Triple option plans are intended to prevent the problem of covering members who are sicker than the general population, which is called __________ selection.
adverse
Medicare calls its remittance advice a(n) __________.
Medicare calls its remittance advice a(n) __________.
provider remittance notice
The computer-to-computer transfer of data between providers and third-party payers (or providers and health care clearinghouses) in a data format agreed upon by sending and receiving parties is called electronic __________.
The computer-to-computer transfer of data between providers and third-party payers (or providers and health care clearinghouses) in a data format agreed upon by sending and receiving parties is called electronic __________.
data interchange
Which is a legal action that can be used to recover a debt and is usually a last resort for a medical practice?
Which is a legal action that can be used to recover a debt and is usually a last resort for a medical practice?
litigation
Which means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim?
Which means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim?
accept assignment
When applying the birthday rule, if policyholders have identical birthdays, the policy in effect the __________ is considered primary.
When applying the birthday rule, if policyholders have identical birthdays, the policy in effect the __________ is considered primary.
longest
Managed care plans that are “federally qualified” and those that must comply with state quality review mandates, or __________, are required to establish quality assurance programs.
Managed care plans that are “federally qualified” and those that must comply with state quality review mandates, or __________, are required to establish quality assurance programs.
laws
A triple option plan is also called a __________ or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator.
A triple option plan is also called a __________ or flexible benefit plan because of the different benefit plans and extra coverage options provided through the insurer or third-party administrator.
cafeteria plan
The Amendment to the HMO Act of 1973 allowed federally qualified HMOs to permit members to __________.
The Amendment to the HMO Act of 1973 allowed federally qualified HMOs to permit members to __________.
occasionally use non-HMO physicians and be partially reimbursed
Any procedure or service reported on the claim that is not included on the master benefit list is a noncovered benefit and will result in claims __________.
Any procedure or service reported on the claim that is not included on the master benefit list is a noncovered benefit and will result in claims __________.
denial
The manual daily accounts receivable journal is also known as the __________, and it is achronologic summary of all transactions posted to individual patient ledgers/accounts on a specific date.
The manual daily accounts receivable journal is also known as the __________, and it is achronologic summary of all transactions posted to individual patient ledgers/accounts on a specific date.
day sheet
One reason to track unpaid claims is due to the payment error in which a patient erroneously cashes a check made out to both patient and provider, which is called a __________.
One reason to track unpaid claims is due to the payment error in which a patient erroneously cashes a check made out to both patient and provider, which is called a __________.
two-party check
Which person is responsible for paying the charges?
Which person is responsible for paying the charges?
guarantor
When selecting a clearinghouse, providers may also want to determine whether it is accredited by the __________.
When selecting a clearinghouse, providers may also want to determine whether it is accredited by the __________.
Electronic Healthcare Network Accreditation Commission
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