1. The document submitted to the payer requesting reimbursement is called a(n) a. explanation of benefits. b. health insurance claim. c. remittance advice. d. preauthorization form.
2. A healthcare practitioner is also called a a. dealer. b. provider. c. purveyor. d. supplier.
The correct answer and explanation is:
1. The document submitted to the payer requesting reimbursement is called a: b. health insurance claim.
A health insurance claim is a formal request sent by a healthcare provider or the patient to an insurance company to reimburse for medical services rendered. This document contains detailed information about the treatment, services provided, associated costs, and the patient’s insurance information.
Healthcare providers often file claims electronically using software or clearinghouses that communicate directly with the payer. Claims include details such as diagnosis codes (ICD codes), procedure codes (CPT codes), and itemized charges for the services. This allows the payer to evaluate whether the services are covered under the patient’s policy and determine the amount to reimburse the provider or patient.
The health insurance claim process ensures that healthcare providers receive payment for their services and patients pay only their share, such as copayments or deductibles. Commonly used forms include the CMS-1500 for outpatient services and the UB-04 for hospital claims. Filing accurate claims is crucial, as errors can lead to delays or denials in reimbursement.
2. A healthcare practitioner is also called a: b. provider.
In the healthcare industry, the term provider refers to any individual or organization licensed to deliver medical care or health services. Providers include physicians, nurses, therapists, dentists, chiropractors, and other licensed professionals. Hospitals, clinics, and nursing homes are also considered providers.
The role of a provider encompasses diagnosing and treating illnesses, promoting health, and managing chronic conditions. Providers work directly with patients to deliver medical care and indirectly by coordinating with insurers, laboratories, and other healthcare professionals.
Providers are central to the healthcare system, as they ensure that patients receive the necessary treatments and care. They also act as a bridge between patients and payers by submitting health insurance claims to ensure proper reimbursement for services rendered.