Joe and Mary are a married couple and both carry insurance from their employers. Joe was born on February 23, 1977 and Mary was born on April 4, 1974. Using the birthday rule, who carries the primary insurance for their children for billing? A. Joe, because he is the male head of the household. B. Mary, because her date of birth is the 4th and Joe’s date of birth is the 23rd. C. Mary, because her birth year is before Joe’s birth year. D. Joe, because his birth month and day are before Mary’s birth month and day. (answer) D. Joe, because his birth month and day are before Mary’s birth month andday.
Which type of managed care insurance allows patients to self-refer to out-of-network providers and pay a higher co-insurance/copay amount? I. HMO II. PPO III. EPO IV.POS V.Capitation A. II B. IV C. II and IV D. II, III, and V (answer) C. II and IV
A patient covered by a PPO is scheduled for knee replacement surgery. The biller contacts the insurance carrier to verify benefits and preauthorize the procedure. The carrier verifies the patient has a $500 deductible which must be met. After the deductible, the PPO will pay 80% of the claim.The contracted rate for the procedure is $2,500.What is the patient’s responsibility? A. $400 B. $500 C. $900 D. $1,600 (answer) C. $900
When a nonparticipating provider files a claim for a patient to BC/BS, how is the payment processed?
A.The payment is sent to the patient and the patient must pay the provider. B.The payment is sent to the provider if the provider agrees to accept assignment. C.The payment is sent to the provider regardless if he accepts assignment. D.The claim is not paid because the provider is not participating in the plan. (answer) A.The payment is sent to the patient and the patient must pay the provider.
Which of the following TRICARE options is/are available to active duty service members? A.TRICARE Select B.TRICARE Prime C.TRICARE For Life D.TRICAREYoung Adult (answer) B. TRICARE Prime
A Medicare card will list which of the following I. Effective date of coverage II. Home address III.Telephone Number IV.Entitled to Part A and/or Part B V.When coverage ends VI. Name of Primary Care Physician A. I – VI B. I, IV C. I-III, VI D. I, II, IV,V (answer) B. I, IV
In which of the following scenarios is Medicare the secondary payer? I. A 65 year-old patient who is collecting her deceased spouse’s Medicare benefits and has a supplemental insurance II. A 72 year-old patient who participates in the group health insurance of his employer III. A 66 year-old patient is injured at work and the employer does not offer health insurance as a benefit of employment IV.A 55 year-old patient who is on disability through Social Security and qualifies for Medicaid and Medicare