HCM 425 Final Exam - Questions and Answers

HCM 425 Final Exam - Questions and Answers Programs of All-inclusive Care for the Elderly (PACE) work to limit out-of-pocket costs to beneficiaries by not applying deductibles, copayments, or other cost-sharing. Which is subject to Medicaid preauthorization guidelines? any extension of inpatient acute care hospital days Which services are exempt from Medicaid copayments? family planning services An individual whose income is a t or below 100 percent of the federal poverty level (FPL) and has resources at or below twice the standard allowed under the SSI program may receive assistance from Medicaid to pay for Medicare premiums,, deductibles, and coinsurance amounts as a qualified Medicare beneficiary (QMB). Which is considered a commercial health insurance company? Prudential Another term that can be used to indicate a fee-for-service plan is a ________ plan. Noncapitated When a patient is covered by a large employer group health plan (EGHP), and the patient is also a Medicare beneficiary, ______ is primary. EGHP Logan is the daughter of Amy (DOB 3/29/68) and Bill (DOB 11/15/70) and is covered by both parents' health insurance plans. According to the birthday rule, a medical claim for Logan will be submitted to Amy's plan as primary payer and Bill's plan as secondary payer. Reimbursement for income lost as a result of a temporary or permanent illness or injury is covered by _____ insurance. Disability When an insurance claim is submitted to an insurance company that covers the treatment of injuries sustained in a motor vehicle accident, the _______ reviews the claim and determines coverage for the injured person. medical adjuster Which claims are submitted to cover the cost of medical care for traumatic, injuries, lost wages, pain, and suffering? Liability A balance of $12.55 is due to the patient for services provided by Dr. Brown. What is entered in Block 30 of the CMS-1500 claim? left blank When the same commercial payer issues the primary and secondary or supplemental policies, it is generally acceptable to submit _______ claim(s). One Which health plan is required to accept employees and their family members? Group BlueCross facilities that had signed contracts to provide services to subscribers for special rates were known as _____ hospitals. Member Which is a function of the BlueCross BlueShield Association (BCBSA)? national advertising, and owns and manages the BCBS trademarks and names The difference between for-profit status and nonprofit status is that for profit corporations pay taxes on profits generated by the corporation. When a policyholder moves into an area served by a different BCBS corporation than the policyholder previously used, the plan must allow conversion and guarantee transfer of membership. The preferred provider network (PPN) allowed rate is generally 10 percent lower than the participating provider rate Which is an incentive for a provider in sign a PPN contract? written notification of new employer groups and hospitals An example of a benefit provided by BCBS basic coverage is assistant surgeon fees. The BCBS plan type that offers choice and flexibility to subscribers is indemnity coverage. A special accidental injury rider provides which benefit? Nonsurgical care is paid at 100 percent if treatment is received within the contract's established time frame. What special handling is required for BCBS claims filed under the medical emergency care rider? ICD-10-CM codes must reflect a condition that requires immediate care.