#1
What does EOB stand for in medical insurance?
Explanation of Benefits
ExplanationStatement detailing medical treatments/services paid for on behalf of the patient.
#2
What is a common method for submitting medical insurance claims?
Electronic Data Interchange (EDI)
ExplanationElectronic exchange of healthcare information.
#3
Which of the following is NOT typically covered by medical insurance?
Cosmetic surgery
ExplanationElective procedures for aesthetic purposes.
#4
What is a deductible in medical insurance?
The amount the insured must pay out-of-pocket before the insurance company will cover expenses
ExplanationInitial out-of-pocket amount before coverage starts.
#5
Which of the following is an example of a healthcare provider?
Pharmacist
ExplanationProfessional involved in providing healthcare services.
#6
What does the term 'co-payment' mean in medical insurance?
The amount the insured must pay each time they receive medical services
ExplanationFixed amount paid at each medical visit.
#7
What is the role of a clearinghouse in medical insurance claim processing?
To process claims on behalf of healthcare providers
ExplanationFacilitates electronic transactions between providers and payers.
#8
What is a common reason for claim denials in medical insurance?
Submitting claims with inaccurate information
ExplanationErrors or discrepancies in claim submissions.
#9
What is the purpose of a CMS-1500 form in medical insurance?
To submit healthcare claims
ExplanationStandard form used for submitting healthcare claims.
#10
What is a common term used to describe the maximum amount an insurer will pay for a covered healthcare service?
Allowable Charge
ExplanationMaximum payment amount for covered services.
#11
What is a pre-authorization requirement in medical insurance?
A requirement to obtain permission before receiving certain medical services
ExplanationApproval needed before specific medical services.
#12
In medical insurance, what does the term 'network provider' refer to?
A provider that is part of an insurance company's approved list
ExplanationProvider contracted with the insurance company.
#13
What does COB stand for in medical insurance?
Coordination of Benefits
ExplanationProcess of coordinating multiple insurance policies to avoid overpayment.
#14
Which entity determines the coverage and reimbursement rules for medical insurance claims?
Insurance carriers
ExplanationEstablishes coverage and reimbursement guidelines.
#15
What does DRG stand for in the context of medical insurance?
Diagnosis-Related Group
ExplanationClassification system for hospital cases.
#16
Which of the following is a potential consequence of submitting fraudulent medical insurance claims?
Legal action and penalties
ExplanationLegal repercussions for fraudulent claims.
#17
What is the role of a utilization review in medical insurance?
To review medical treatment to ensure it's appropriate and necessary
ExplanationAssessing medical necessity and appropriateness of care.
#18
What is the purpose of a medical claim audit?
To identify billing errors and potential fraud
ExplanationExamination of medical claims for accuracy and compliance.