BILLING AND CODING BUNDLED PRACTICE
SOLUTION 2026 TESTED QUESTIONS AND
EXPERT VERIFIED ANSWERS GUARANTEED TO
PASS
◉ Policyholder.
Answer: Person who buys an insurance plan; the insured, subscriber,
or guarantor
◉ Health Plan.
Answer: Individual or group plan that provides or pays for the cost
of medical care
◉ Benefits.
Answer: What a health plan pays for services covered in an
insurance policy; listed in the schedule of benefits.
◉ Medical Necessity.
Answer: Reasonable services of provider (doctor or facility)
consistent with professional medical standards.
◉ Covered Services.
,Answer: Determined as being medically necessary and both
reasonable and consistent with the standards for the diagnosis or
treatment of injury or illness.
◉ Non-covered Services.
Answer: Medical procedures not covered in a plans benefits.
◉ Individual Health Plan (I H P).
Answer: contract between individual and the plan
known as direct pay.
◉ Group Health Plan (G H P).
Answer: contract between an employer or organization and the plan,
the group members are insured as "subscribers".
◉ Disability Insurance.
Answer: Replaces income lost because the insured cannot work
◉ Workers' Compensation Insurance.
Answer: Provides benefits for an insured injured on the job
◉ Indemnity Insurance.
,Answer: Payment method is fee-for-service based on the contract's
schedule of benefits,fee is paid AFTER the patient receives services
from the physician.
◉ Managed care.
Answer: A system that combines the financing and the delivery of
appropriate, cost-effective health care services to its members.
◉ Premium.
Answer: Periodic payment the patient is required to make to keep
the policy in effect.
◉ Deductible.
Answer: Amount that the insured pays on covered services before
benefits begin.
◉ Coinsurance.
Answer: Percentage of each claim that the insured pays; states the
health plan's percentage of the charge, followed by the insured's
percentage.
◉ Health Maintenance Organizations (HMOs).
, Answer: A manged health care system in which providers agree to
offer healthcare to the organization's members for fixed periodic
payments from the plan.
◉ capitation Method.
Answer: a fixed prepayment made to the medical provider for all
necessary contracted services provided to each patient who is a plan
member no matter how much medical care is received during the
determined time period.
◉ Per member per month, (PMPM).
Answer: (per member per month): The "capitated rate" Capitation
this amount is paid to the health care provider based on the
schedule of benefits, no matter how much medical care is received
during the determined time period.
◉ Point of Service Plan (PPO).
Answer: Combines features of both HMOs and PPOs Also called an
"open access HMO "Allows members to see providers in or out of
HMO's network Members pay more for out-of-network providers.
◉ Preferred Provider Organizations (PPO).
Answer: A managed care organization structured as a network of
health care providers who agree to perform services for plan
members at discounted fees; usually, plan members can receive
SOLUTION 2026 TESTED QUESTIONS AND
EXPERT VERIFIED ANSWERS GUARANTEED TO
PASS
◉ Policyholder.
Answer: Person who buys an insurance plan; the insured, subscriber,
or guarantor
◉ Health Plan.
Answer: Individual or group plan that provides or pays for the cost
of medical care
◉ Benefits.
Answer: What a health plan pays for services covered in an
insurance policy; listed in the schedule of benefits.
◉ Medical Necessity.
Answer: Reasonable services of provider (doctor or facility)
consistent with professional medical standards.
◉ Covered Services.
,Answer: Determined as being medically necessary and both
reasonable and consistent with the standards for the diagnosis or
treatment of injury or illness.
◉ Non-covered Services.
Answer: Medical procedures not covered in a plans benefits.
◉ Individual Health Plan (I H P).
Answer: contract between individual and the plan
known as direct pay.
◉ Group Health Plan (G H P).
Answer: contract between an employer or organization and the plan,
the group members are insured as "subscribers".
◉ Disability Insurance.
Answer: Replaces income lost because the insured cannot work
◉ Workers' Compensation Insurance.
Answer: Provides benefits for an insured injured on the job
◉ Indemnity Insurance.
,Answer: Payment method is fee-for-service based on the contract's
schedule of benefits,fee is paid AFTER the patient receives services
from the physician.
◉ Managed care.
Answer: A system that combines the financing and the delivery of
appropriate, cost-effective health care services to its members.
◉ Premium.
Answer: Periodic payment the patient is required to make to keep
the policy in effect.
◉ Deductible.
Answer: Amount that the insured pays on covered services before
benefits begin.
◉ Coinsurance.
Answer: Percentage of each claim that the insured pays; states the
health plan's percentage of the charge, followed by the insured's
percentage.
◉ Health Maintenance Organizations (HMOs).
, Answer: A manged health care system in which providers agree to
offer healthcare to the organization's members for fixed periodic
payments from the plan.
◉ capitation Method.
Answer: a fixed prepayment made to the medical provider for all
necessary contracted services provided to each patient who is a plan
member no matter how much medical care is received during the
determined time period.
◉ Per member per month, (PMPM).
Answer: (per member per month): The "capitated rate" Capitation
this amount is paid to the health care provider based on the
schedule of benefits, no matter how much medical care is received
during the determined time period.
◉ Point of Service Plan (PPO).
Answer: Combines features of both HMOs and PPOs Also called an
"open access HMO "Allows members to see providers in or out of
HMO's network Members pay more for out-of-network providers.
◉ Preferred Provider Organizations (PPO).
Answer: A managed care organization structured as a network of
health care providers who agree to perform services for plan
members at discounted fees; usually, plan members can receive
