OIC - Applying Concepts Ch 2 #6
6. The patient's insurance plan pays 80 percent of eye examinations for preventive care but does not pay for ophthalmology services related to refractions; the patient is responsible for these charges. The patient is examined by an ophthalmologist and prescribed corrective lenses, The bill is detailed as follows:
What amount is covered by the patient's insurance plan? What amount must the patient pay?
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Outpatient Insurance Coding - Applying Concepts Ch 1
1. The patient's health insurance plan has a $750 deductible for hospital visits, and then it covers 100 percent of hospital visit charges. The patient's first hospital visit this year had charges of $612. The patient was subsequently admitted to the hospital a second time this year, and the charges totaled $358. How much will the patient be billed for each visit? How much will the health insurance plan reimburse for each visit?2 A patient insured under an indemnity plan...
OIC - Applying Concepts Ch 3 #4
4. Lisa Perez was seen in your office twice last fall. Her deductible has been met and her coinsurance is 85-15. In October, she was seen for influenza vaccination, and her insurance company was billed $13.00 for the vaccine and $9.00 for the administration of the vaccine. Lisa's schedule of benefits for her indemnity insurance plan lists the influenza administration as being a covered service, but it does not include the actual vaccine. In December, Lisa had an office visit...
OIC - Applying Concepts Ch 3 #3
3. Mike Moroni is covered by a member health plan with a 20 percent discount from the provider's ual fear d a 520.00 copay. The charges are $365.50. What amount will the HMO pay? What does the patient owe?
Outpatient Insurance Coding - Applying Concepts Ch 3
1. The patient is insured by a PPO with 100 percent coverage after a copay of $15. The patient was seen in the office for a checkup, and the total charges were $115. What amount must the patient pay? When? What amount must the insurance plan pay? When?2 Afaf Darcy is insured by an HMO with a $10 copay and out-of-network coinsurance on charge balances of 90-10. She needed ysical therapy after her knee replacement. Her HMO pays for eighteen...
OIC - Applying Concepts Ch 2 #7
7. Sheena's health plan has a $250 deductible for each person or a maximum deductible of $1,000 for a family of more than four people per year. Once the deductible has been met, the plan reimburses on a 90-10 basis. Sheena's son, Shane, frequently sees a healthcare provider for a chronic illness. In fact, he was seen in the office on 1/14, 2/3, 2/24, 3/7, and 3/11 this year; his office visit charges total $375. Sheena's daughter, Sharon, had office...
OIC - Applying Concepts Ch 2 #5
5. The patient has two insurance policies. Each policy's coinsurance is 80-20. If the patient has charges totaling $845, what amount should the medical insurance specialist expect to be reimbursed from Insurer A? From Insurer B? For what amount should the patient be billed?
OIC - Applying Concepts Ch 2 #4
4. Holly Hiker is insured by an HMO whose network is exclusive to her home city in Pennsylvania. The HMO expects patients to pay any costs up front when accessing healthcare services out of network; the patient then submits the charges for 80 percent reimbursement except in emergency cases when 100 percent is reimbursed. She had a life threatening injury while on a hiking vacation in Maine. She received treatment at the local trauma center's emergency room that cost $1,732....
OIC - Applying Concepts Ch 3 #2
2. Afaf Darcy is insured by an HMO with a $10 copay and out-of-network coinsurance on charge balances of 90-10. She needed ysical therapy after her knee replacement. Her HMO pays for eighteen physical therapy sessions in such cases at a rate of $63.50 per visit. If additional physical therapy is needed, the provider must document the reasons and submit a formal request. The therapist requested additional visits, and Ms. Darcy attended five additional physical therapy sessions. The request was...
Ch 16 Case Studies #8
As with a Medicare RA, when a commercial RA is received, before posting payments and preparing secondary claims that may be required you must carefully review it. When analyzing an RA from a commercial carrier, you must be familiar with the guidelines of that carrier’s particular plan. The type of services covered and the percentage of the coverage will vary, depending on whether the plan is a fee-for-service plan, a managed care plan, a consumer-driven health plan, or some other...
pilallon. u Uchinition of 57. The process of determining if a procedure or service is covered...
pilallon. u Uchinition of 57. The process of determining if a procedure or service is covered by the insurance plan and what the reimbursement is for that procedure is the definition of a. eligibility b. precertification. c. medical necessity. d. capitation 38. The provider is paid a set amount for cach enrolled person assigned to them, per period of time whether or not that person has received services is the definition of a. eligibility b. Precertification. c. medical necessity. d....
pilallon. u Uchinition of 57. The process of determining if a procedure or service is covered by the insurance plan and what the reimbursement is for that procedure is the definition of a. eligibility b. precertification. c. medical necessity. d. capitation 38. The provider is paid a set amount for cach enrolled person assigned to them, per period of time whether or not that person has received services is the definition of a. eligibility b. Precertification. c. medical necessity. d....
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