Graded Homework

1. Match the terms in the left column with
the definitions in the right column by writing letters in the blanks.

third-party payer indemnity deductible carrier adjuster fiscal intermediary elimination period assignment partial disability	a. employee of an insurance carrier with whom a case is assigned and who follows the case until it is settled b. contractor that processes payments to providers on behalf of state or federal agencies or insurance companies c. insurance carrier that intervenes to pay hospital or medical expenses on behalf of beneficiaries or recipients d. benefits paid in a predetermined amount in the event of a covered loss e. the transfer of one’s right to collect an amount payable under an insurance contract f. organization that offers protection against losses in exchange for a premium g. form of cost sharing in which the insured pays a specific portion toward the amount of the professional services rendered h. period of time after the beginning of a disability for which no benefits are payable i. illness or injury preventing the insured from performing one or more functions of his or her occupation j. amount the insured must pay in a fiscal year before an insurance company will begin the payment of benefits

2. Name and give a brief definition of
three types of commercial (private) health insurance plans.

a.

b.

c.

3. The insured is also known as a/an
______________________________ or ____________________________.

4. The abbreviation for an insurance plan
that has a high annual deductible is a/an:

a.
HSA

b. HFSA

c. HDHP

d. UCR

e. COB

5. An elimination period written in an
insurance policy may also be known as a/an ____________________

________________________ or
____________________________________________________________________.

6. An attachment to a policy excluding
certain illnesses or disabilities is called a/an ____________________

.

7. Managed care plans pay the physician by
_________________________________________________________.

8. Dr. Practon wants to know if Mrs. Snow’s
managed care plan covers a particular surgical procedure.

This is a process known as .

9. Dr. Practon completes a form for
preauthorization of a diagnostic test to be ordered for Lee Cho. This

process may also be called
_________________________________ or .

10. Before scheduling elective surgery on
Phyllis Horton, Dr. Practon wants to know the maximum amount

the insurance plan will pay. This is a
process known as

.

11. Name five popular types of managed care
health plans and list their abbreviations.

a.

b.

c.

d.

e.

12. Participating physicians receive
_________________ percent of the allowable fee paid by Medicare.

13. Circle the correct answer. A [participating
or nonparticipating] physician may not bill more than the

Medicare limiting charge.

14. What is the time limit for submission
of a Medicare claim?

15. A document from the insurance company
that arrives with a check for payment of an insurance claim is

called a/an
___________________________________________________________________________________

______________________________________________________________________________________________.

In
the Medicare program, this document is called a/an
____________________________________________,

and the one sent to patients is called a/an
_______________________________________________________.

16. Circle the correct answer. Medicare
Part D is [voluntary or involuntary] prescription drug coverage offered by
[government or private] insurance carriers.

17. Circle the correct answer. When
submitting a Medicare/Medicaid claim, the physician [should, should

not, must always] accept assignment or
payment will go to the patient.

18. A claim processed by Medicare and
automatically processed by Medicaid is referred to as a/an

claim.

19. The TRICARE fiscal year is from
_______________________________ to _______________________________.

20. Define the following terms in relation
to disability insurance.

a.
Temporary disability:
_______________________________________________________________________

b. Partial disability:

c. Total disability:

21. After an initial workers’ compensation
report, insurance carriers want progress reports submitted on the

injured worker each time the patient is
seen, or on a/an _____________________________________________ basis.

22. The paper insurance claim form that is
accepted by most commercial (private) insurance companies,

Medicare, Medicaid, and TRICARE is called
the .

23. If a patient signs an assignment of
benefits statement, where is the insurance check sent?

24. The birthday rule:

a.
is honored in most states

b. helps determine the primary insurance
plan when a child is covered by both parents

c. may not apply in divorce situations

d. does not apply in Hawaii

e. all are correct

25. The standard unique health identifier
that all health care providers use when submitting claims is called

the .

26. A service that receives insurance
claims, edits and sorts them, and then electronically transmits them to

insurance companies is called a/an .

27. Indicate whether the following
statements are true (T) or false (F).

a.
________ Only an original CMS-1500 claim form may be optically scanned.

b. ________ It is permissible to type data
in lowercase for claims being optically scanned.

c. ________ When entering data on a claim
that is to be optically scanned, dates are keyed in using six digits.

d. ________ Staples and paper clips may be
used for attachments when sending insurance claims.

28. Which is the new version of the data
element field that will need to be used for electronic billing

starting January 1, 2012?

a.
5010

b. 1500

c. 13

d. 4010

e. 640

29. If payment is not received after
inquires have been made, a/an ________________ may need to be filed.