Exam 6: Traditional Fee For Service/Private Plans

Many self-insured groups hire a specific type of organization to manage and pay claims called:

The legislation that includes a mandate that insurance companies must cover certain preventive services for those who purchased or joined a new plan on or after September 23,2010,without charging out-of-pocket costs,is:

Any organization (e.g.,Medicare or commercial insurance company)that provides payment for specified services covered under a health insurance plan is referred to as a _______________________.

A self-insured health plan can only be offered by the federal government.

Identify the term that refers to the commonly charged or prevailing fees for health services within a geographic area.

When switching jobs,HIPAA guarantees the same level of benefits,deductibles,and claim limits the individual might have had under the former employer's health plan.

Define "commercial" health insurance.

Submitting claims to third-party carriers within the time limits set forth in the payer's guidelines is referred to as _____ filing.

Consumer directed health plans (CDHPs)often involve pairing a high deductible PPO plan with a tax-advantaged account,such as a health savings account (HSA).

Blue Cross and Blue Shield organizations are governed at the national level.

The "traditional" type of health insurance policy whereby the insurance company pays all or a portion of the fees for the services provided to the individual covered by the policy is called:

Identify the recent federal act that amended HIPAA's "credible coverage" rule.

In addition to the premium,an out-of-pocket amount that usually must be paid before insurance payments begin is called the ___________.

How would the health insurance professional identify members of the BlueCard Program?

An organization that determines payment for Part B-covered items and provider services is now more commonly called a ______________________.

HIPAA-AS sets standards for the electronic transmission of healthcare data and to protect the privacy of individually identifiable healthcare information.

The type of provider that enters into a contractual agreement with the carrier and agrees to follow the payer's specific rules involving claims and payment in return for certain advantages is called a ________ provider.

A/An ___________________ allows payments to be posted to patients' accounts automatically,eliminating manual posting of claim payments to both electronic and paper claims.

If the health insurance professional needs to know a particular carrier's rules for completing the CMS-1500,the best thing to do is to:

Name the type of managed care plan that combines characteristics of both the HMO and the PPO.