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kduvall20
Health Insurance today Chapter 11,
| Question | Answer |
|---|---|
| A well defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment | observation care |
| This occurs when a physician in the community refers a patient to the hospital for observation, bypassing the clinic or emergency department | direct admission |
| Usually covers the deductible and copay or coinsurance of a primary health insurance policy | supplemental plan |
| The legal business name of the practice | billing entity |
| Supplemental plans designed by the federal government but sold by private commercial insurancies companies to "cover the gaps in Medicare" | medigap |
| An employee sponsored health benefits program established by an act of congress in 1959 | federal employee health benefits program (FEHBP) |
| This enables such members obtaining healthcare services while traveling or living in another BCBS plan's service area to reveive benefits oftheir home plan contract and to access local provider networks | bluecard program |
| Special clauses stipulating additional coverage over and above the standard contract | riders |
| Offers choice and flexibility to subscribers who want to receive a full range of benefits along with the freedom to use any licensed health care provider | idemnity coverage |
| The amount commonly charged for a particular medical service by providers within a particular geographic region for establishing their allowable rates | usual, customary,and reasonable (UCR) |
| HIPAA privacy standards require providers to notify patients about their right to | privacy |
| Development of an insurance claim begins when the: | patient contacts the provider's office and schedules an appointment |
| When a fee submitted to an insurance company is higher than the health care provider's normal fee for the coded procedure,the provider must: | attach a letter to the claim explaining the rationale for the higher charge |
| Optical character reader (OCR) guidelines were established when the : | CMS 1500 claim form was developed |
| When typewritten data is CMS-1500 claim form runs over into adjacent blocks, the claim will be: | rejected and returned to the provider |
| Which is the proper way to prepare a rejected claim for resubmission? | create the corrected claim on an original (red-print) claim form |
| Remittance advice forms that are organized and filed according to month and payer are: | open assigned cases |
| Another term that can be used to indicate a fee-for-service plan is a ____________ plan | noncapitated |
| Benefits such as coverage for copayments, deductibles, and coinsurance are offered by which type of insurance plan? | supplemental |
| Proir to the joint venture between Blue Cross and Blue Shield, the Blue Shield plans covered only: | physician services |
| Blue Cross facilities that had signed contracts to provide services to subscribers for special rates were known as_______hospitals | member |
| Which is the function of the BlueCross BlueShield Association(BCBSA) | national advertising |
| The preferred provider network (PPN) allowed rate is generally: | 10 percent lower than the participating provider rate |
| Small businesses are likely to select which BCBS coverage? | fee-for-service |
| What is an example of a benefit covered by BCBS basic coverage? | assistant surgeon fees |
| What BCBS plan type offers the most flexibility for subscribers? | indemnity coverage |
| The outpatient pretreatment authorization plan (OPAP) is also known as: | precertification |
| What title is listed on the BCBS identification cards for federal employees? | government-wide service benefit plan |
| BCBS Medicare supplemental plans are also known as? | medigap |
| Which is a program that requires providers to adhere to managed care provisions | preferred provider network |
| One of the expectations that nonparticipating provider has is to_____for services rendered: | obtain payment for the full fee charged |
| Which is considered a minimum benefit under BCBS basic coverage? | hospitalizations |
| Which is considered a service reimbursed by BCBS major medical coverage? | mental health visits |
| Which is a special clause in an insurance contract that stipulates additional coverage over and over and above the standard contract? | rider |
| Prospective authorization or precertification is a requirement of the_____BCBS managed care plan | outpatient pretreatment authorization |
Created by:
kduvall20
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