5 Written Questions

1. grants prior approval for reimbursement of a healthcare service
2. provide better access to health insurance, limit fraud & abuse, & reduce administrative costs.
3. the percentage the patient pays for covered services after the deductible has been met & the copayment has been paid
4. 1908 - workmen compensation
5. PPO

5 Matching Questions

1. First Blue Cross policy:
2. Subscriber:
3. What year Blue Shield started:
4. DRG's:
5. Concurrent review:

1. a prospective payment system that reimburses hospitals for impatient stays
2. b review for medical necessity of tests/procedures ordered during inpatient hospitalization
3. c introduced a plan to guarantee school teachers 21 days of hospital care for 46 a year.
4. d person in whose name the insurance policy is issued
5. e 1939

5 Multiple Choice Questions

1. provider accepts preestablished payments for providing healthcare services to enrollness over a period of time (usually one year)
   1. Deductible:
   2. Capitation:
   3. HIPPA is to:
   4. Copayment:
2. 1860 by The Franklin Health Assurance Company of Massachusetts was the first commercial insurance company in the US to provide private healthcare coverage for injuries not resulting in death.
   1. First Blue Cross policy:
   2. Group Health Insurance
   3. First Health Insurance Policy in
   4. Coinsurance:
3. network of physicians & hospitals that have joined together to contract w/insurance companies, employers.
   1. Preferred provider Organization (PPO):
   2. Exclusive Provider Organization (EPO):
   3. Preferred providers:
   4. Managed Care Organizations (MCO):
4. which describes patient encounters with provides for the purpose of evaluation & management of general health status.
   1. What year for Group Health Insurance:
   2. Managed Care Organizations (MCO):
   3. 1991 E/M codes created(Evaluation & Management:
   4. Health Maintenance Organization came in effect in
5. HCFA (now called CMS) required providers to use the HCFA-1500 (now called the CMS-1500) to submit Medicare claims
   1. International Classification of Diseases (ICD):
   2. Health Maintenance Organization came in effect in
   3. 1984 Standardization of information submitted on Medicare claims:
   4. Clinical Laboratory Improvement Act (CLIA):

5 True/False Questions

1. Point-of-Service Plan (POS): → reimbursement methodology that increases payment if the healthcare service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services

   True        False

2. Utilization review: → review for medical necessity of inpatient care prior to admission

   True        False

3. Preauthorization: → prior approval

   True        False

4. Major medical: → coverage for catastrophic or prolonged illness & injuries

   True        False

5. Integrated Delivery System (IDS): → organization of affiliated providers' sites that offer joint healthcare services to subscribers

   True        False