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HCA study guide
| Question | Answer |
|---|---|
| Medicare covers ____ percent of the approved medical expenses once the deductible is satisfied | 80% |
| Part ___ of Medicare provides coverage for prescription drugs, including both generic and brand name medications | Part D |
| a persons ___is the fixed amount they pay at the time of service for a covered healthcare service | copayment |
| the ___ is the amount an insured individual must pay out of pocket before their insurance begins to pay. | deductible |
| The ____ _____ Act of 1965 led to the creation of medicare and medicaid | Social security |
| a patients ___ is the amount billed by a provider for healthcare services | charges |
| The CMS-1500 form is primarily used to submit claims to ___ and certain government insurers | Medicare |
| The spouse of a veteran who dies from a service-connected condition may be eligible for ____ /____ coverage. | Champ VA/ TRICARE |
| When a claim contains errors, the insurance company may ____ the claim and request corrections | reject |
| ___ _____ adjudication allows providers to determine what a patient owes and what insurance will pay at the time of service | real time |
| The process of discovering the maximum amount of money an insurance carrier will pay for a specific service is called | predetermination |
| a document sent by an insurance company that details what was covered for a medical service and what the patient owes is called an | Explanation of benefits |
| a ____ is a request for payment submitted to an insurer for services rendered | claim |
| The amount paid periodically to an insurance company for health coverage is known as the | premium |
| A healthcare provider who participates in an insurance network is referred to as a ____ provider | participating |
| ________ is when a provider knowingly bills for services not provided or medically unnecessary | fraud |
| covers impatient services such as hospital stays and skilled nursing care | Part A |
| covers outpatient services such as doctor visits and outpatient care | Part B |
| an advance _____ notice (ABN) informs a patient that a service may not be covered by medicare and may be responsible for the cost | beneficiary |
| When a patient has both medicare and medicaid, ______ acts as the primary insurance payer | medicare |
| Modifiers for CPT codes can be found in the _____ A of the CPT manual | appendix |
| The _______ section on a claim form ensures proper payment by all responsible parties, including primary and secondary payers | coordination of benefits |
| A healthcare provider submits claims to a ________ which processes and forwards them to insurance carriers | clearinghouses |
| The ___ insurance model requires patients to obtain referrals from their PCP before seeing a specialist | HMO |
| The process of electronically submitting claims has ______ the turnaround time for insurance payments | reduced/ shortened |
| The health insurance portability and accountability act (HIPAA) established rules to protect the _____ of patient health information | privacy |
| The international classification of diseases (ICD) codes describe a patients ____ or condition | diagnoses |
| Current Procedural Terminology (CPT) codes describe the ____ provided to a patient | procedures |
| Medicare part D is offered through private insurance companies that are _____ by medicare | approved |
| A patient who has NOT met their annual deductible will need to pay _____% for healthcare services until the deductible is met | 100 |
| A clearinghouse often charges a ______ fee for processing claims | transaction |
| The social security act of 1965 also establishes the ______ program to assist low income individuals with healthcare costs | Medicaid |
| A patients copayment amount can often be determined before their visit using ____ _____ adjudication | real time |
| a rejected claim can be resubmitted electronically or by the payers requirements | |
| The healthcare common procedure coding system (HCPCS) includes both CPT codes and _______ codes | level 2 |
| If a patient has an indemnity-type plan the providers office will often file the ____ on their behalf | claim |
| Medicares _____ program ensures that participating providers adhere to specific billing rules and guidelines | compliance |
| Nonparticipating providers may require patients to pay ____ for services and file claims themselves | upfront |
| The process of verifying that a patients insurance will cover a procedure is known as | preauthorization |
| a ______ is a fixed percentage of the cost of a service that a patient must pay after meeting their deductible | co insurance |
| The national provider identifier (NPI) is a unique number assigned to each | provider |
| The coordination of ______ section on a claim form ensures that benefits from multiple insurers are applied correctly | benefits |
| If a patient receives services that are not covered by their insurance, the patient is responsible for paying the ____ costs of those services | full |
| providers who bill for services that were not provided or documented may face penalties for | fraud |
| a patients _______ card contains important information about their health insurance coverage including their policy number | insurance |
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