#1
What does the term 'co-payment' refer to in health insurance?
A fixed amount paid by the insured for each office visit or prescription
ExplanationFixed payment by insured for office visit or prescription.
#2
Which of the following is NOT typically covered by health insurance?
Cosmetic surgery
ExplanationCosmetic procedures are usually not covered.
#3
What does the term 'deductible' refer to in health insurance?
The amount an insured person pays out-of-pocket before the insurance company starts paying for covered services
ExplanationAmount paid by insured before coverage starts.
#4
Which of the following healthcare providers typically require pre-authorization for services?
Specialists
ExplanationSpecialists often require pre-authorization.
#5
What is the term used to describe an agreement between a healthcare provider and an insurance company to provide services to members at a pre-negotiated rate?
Provider network
ExplanationPre-negotiated rate agreement for services.
#6
What is the purpose of ICD-10 codes in healthcare billing?
To identify diagnoses and medical conditions
ExplanationUsed for identifying diagnoses and conditions.
#7
Which entity regulates the rules and regulations for health insurance in the United States?
Centers for Medicare & Medicaid Services (CMS)
ExplanationCMS regulates health insurance rules.
#8
What is the purpose of CPT codes in healthcare billing?
To identify medical procedures performed
ExplanationIdentifies medical procedures.
#9
Which federal program provides health coverage for individuals aged 65 and older, as well as certain younger people with disabilities?
Medicare
ExplanationHealth coverage for seniors and some disabled.
#10
What does 'EOC' stand for in health insurance terminology?
Evidence of Coverage
ExplanationAbbreviation for Evidence of Coverage.
#11
What is the purpose of a 'Explanation of Benefits (EOB)' statement in health insurance?
To provide a summary of covered services and claims processed by the insurance company
ExplanationSummarizes covered services and claims.
#12
What is the purpose of a 'claim denial' in health insurance?
To reject coverage of a submitted claim
ExplanationRejects coverage of a submitted claim.
#13
What is the purpose of a 'pre-authorization' requirement in health insurance?
To ensure medical necessity before certain services are performed
ExplanationEnsures medical necessity before services.
#14
What is the purpose of a 'claim adjudication' process in health insurance?
To review and process claims for reimbursement
ExplanationReviews and processes claims for reimbursement.
#15
What is the purpose of a 'utilization review' in health insurance?
To review and approve healthcare services based on medical necessity
ExplanationReviews services based on medical necessity.