QUANTUM HEALTH CORE TRAINING
MODULES QUESTIONS WITH ACTUAL
SOLUTIONS
Premium cc- ccAnswer ccThe ccmoney ccthat ccthe ccemployee cc(and cctypically ccyour
ccemployer) ccpays ccfor ccaccess ccto ccinsurance cccoverage. ccIf ccpurchased ccthrough
ccthe ccemployer, ccthis ccmoney ccis cctypically cctaken ccdirectly ccout ccof ccthe ccemployee's
ccpaycheck ccper ccthe ccfrequency ccdetermined ccby ccthe ccemployer cc(monthly, ccbi-
weekly, ccweekly, ccetc.)
Deductible cc- ccAnswer ccA ccfixed ccdollar ccamount cca cccovered ccmember ccis
ccresponsible ccfor ccpaying ccout ccof ccpocket ccduring ccthe ccplan ccyear ccbefore ccthe
ccinsurance ccbegins ccto ccpay ccfor cccovered ccservices. ccPlans ccmay cchave ccboth cca
ccseparate ccindividual ccand ccfamily ccdeductible ccand ccmay ccdiffer ccfor ccservices
ccprovided ccby ccan ccINN ccphysician ccor ccOON ccphysician.
Copay cc- ccAnswer ccA ccfixed ccdollar ccamount cca cccovered ccmember ccis ccresponsible
ccfor ccpaying ccto ccthe ccprovider ccat ccthe cctime ccof ccservice. ccCopays ccare ccmostly
ccused ccfor ccoffice ccvisits ccto ccthe ccPCP, ccspecialist, ccUrgent ccCare, ccand ccER, ccbut
cconly ccif ccthe ccplan ccis ccdesigned ccwith cca cccopay ccoption.
Coinsurance cc- ccAnswer ccThe ccpercentage ccof cccosts ccshared ccby ccthe ccpatient ccand
ccthe ccinsurance ccplan cctypically ccafter ccthe ccmember's ccdeductible ccis ccmet. ccThese
ccamounts cccan ccvary ccbased ccon ccutilizing ccan ccINN ccprovider ccvs. ccOON ccprovider.
ccProviders cccan ccask ccfor ccthe ccmembers ccportion ccto ccbe ccpaid ccat ccthe cctime ccof
ccservice, ccbut ccsometimes ccis ccdeferred ccby ccthe ccprovider's ccoffice ccuntil ccthe ccclaim
cchas ccbeen ccprocessed ccand ccthe ccexact ccamount ccidentified.
OOP ccMAX cc(Out-of-Pocket ccMaximum) cc- ccAnswer ccThe cctotal ccmaximum ccamount
ccthat cca cccovered ccmember ccof ccfamily ccmember ccis ccresponsible ccfor ccpaying ccout-
of-pocket cctowards ccmedical ccservices ccwithin cca cccalendar ccor ccplan ccyear. ccThe
ccout-of-pocket cc(OOP) ccexpense ccusually ccincludes ccthe ccplan ccdeductible, ccwhat
ccthe ccmember ccpays ccfor ccco-insurance, ccand cc(if ccapplicable) cccopays. ccOnce ccthe
ccOOP ccMaximum cchas ccbeen ccmet, ccthe ccplan ccwill cccover cc100% ccof ccallowable
ccmedical ccexpenses ccby ccan ccINN ccprovider ccfor ccthe ccrest ccof ccthe cccalendar ccor
ccplan ccyear.
, Exclusions cc- ccAnswer ccHealthcare ccservices ccthat ccare ccnot cccovered ccby ccthe
ccplan.
Benefit ccLimitations/Maximums cc- ccAnswer ccWhen cclimitations ccare ccapplied ccto cca
ccplan, ccthe ccplan ccwill ccnot ccpay ccbenefits cconce ccthe cclimitations ccis ccreached, ccor
ccthe cccriteria ccis ccnot ccmet. cc(Example: cc"Covers cc60 ccvisits ccper ccplan ccyear ccfor
ccphysical, ccoccupational, ccand ccspeech cctherapy cccombined.")
Allowed ccAmount cc(Network ccContracted ccRate) cc- ccAnswer ccThe ccmaximum
ccamount cca ccprovider ccwill ccbe ccpaid ccfor cca ccservice. ccThe ccrate ccis ccbased ccon
cctheir cccontract ccwith ccthe ccnetwork. ccBenefits ccare ccpaid ccagainst ccthe cc"allowed
ccamount" ccnot ccthe ccactual cc"charged ccamount." ccINN ccproviders cccannot ccbalance
ccbill ccmembers ccfor ccthe ccdifference ccbetween ccthe ccprovider's cccharged ccamount
ccand ccthe ccmaximum ccallowed ccamount ccfor cccovered ccservices. cc
If cca cccaller ccquestions ccwhat ccthe ccamount ccis ccprior ccto ccservice, ccwe ccdo ccnot
cchave ccaccess ccto ccthis ccprivate cccontract ccinformation ccand ccwould ccneed ccto
ccdirect ccthem ccback ccto cctheir ccprovider ccand/or ccnetwork ccrepresentative.
U cc& ccC cc(Usual cc& ccCustomary) cc- ccAnswer ccThe ccU cc& ccC ccamount ccis ccused
ccwhen ccmembers ccuse ccan ccOON ccprovider. ccThe ccamount ccthat ccthe ccbenefits ccare
ccpaid ccagainst ccis ccbased ccon ccan ccaverage ccof ccwhat ccproviders ccin cca ccgeographic
ccare cccharge ccfor ccthe ccsame ccmedical ccservice. ccOON ccproviders cccan ccbalance
ccbill ccmembers ccfor ccthe ccdifference ccbetween ccthe ccprovider's cccharged ccamount
ccand ccthe ccU cc& ccC ccamount.
If cca ccmember ccor ccprovider ccquestions ccthe ccamount ccprior ccto ccservice, ccwe ccare
ccunable ccto ccprovide ccthem ccwith ccthat ccexact ccamount.
Medicare ccAllowable cc- ccAnswer ccMedicare ccAllowable ccrates ccare ccused ccwhen
ccmembers ccuse ccan ccOON ccprovider. ccThe ccamount ccthat ccbenefits ccare ccpaid
ccagainst ccis ccbased ccon cca ccpercentage ccof ccthe ccrates ccthat ccare ccprovided ccby
ccMedicare. cc(Example: cc110% ccof ccMedicare ccAllowable- ccmeaning ccthe ccrate ccthat
ccbenefits ccwill ccpay ccagainst ccwill ccbe cc110% ccof ccthe ccMedicare ccfee ccschedule).
ccOON ccproviders cccan ccbalance ccbill ccmembers ccfor ccthe ccdifference ccbetween ccthe
cc"charged ccamount" ccand ccthe cc"Medicare ccAllowable" ccamount.
Balance ccBilling cc- ccAnswer ccWhen cca ccprovider ccbills ccyou ccfor ccthe ccdifference
ccbetween ccthe ccprovider's cccharge ccand ccthe ccmaximum ccallowed ccamount
cc(contracted ccrate). cc(Example: ccIf ccthe ccprovider's cccharge ccis cc$100 ccand ccthe
ccallowed ccamount ccis cc$70, ccthe ccdifference/balance ccis cc$30). ccINN ccproviders
cccannot ccbalance ccbill ccfor cccovered ccservices.
Eligibility cc- ccAnswer ccA cccritical ccpiece ccof ccinformation ccthat cctells ccus ccwho ccis
cccovered, ccunder ccwhich ccplan, ccand ccduring ccwhat cctime ccframe. ccMany ccitems cccan
MODULES QUESTIONS WITH ACTUAL
SOLUTIONS
Premium cc- ccAnswer ccThe ccmoney ccthat ccthe ccemployee cc(and cctypically ccyour
ccemployer) ccpays ccfor ccaccess ccto ccinsurance cccoverage. ccIf ccpurchased ccthrough
ccthe ccemployer, ccthis ccmoney ccis cctypically cctaken ccdirectly ccout ccof ccthe ccemployee's
ccpaycheck ccper ccthe ccfrequency ccdetermined ccby ccthe ccemployer cc(monthly, ccbi-
weekly, ccweekly, ccetc.)
Deductible cc- ccAnswer ccA ccfixed ccdollar ccamount cca cccovered ccmember ccis
ccresponsible ccfor ccpaying ccout ccof ccpocket ccduring ccthe ccplan ccyear ccbefore ccthe
ccinsurance ccbegins ccto ccpay ccfor cccovered ccservices. ccPlans ccmay cchave ccboth cca
ccseparate ccindividual ccand ccfamily ccdeductible ccand ccmay ccdiffer ccfor ccservices
ccprovided ccby ccan ccINN ccphysician ccor ccOON ccphysician.
Copay cc- ccAnswer ccA ccfixed ccdollar ccamount cca cccovered ccmember ccis ccresponsible
ccfor ccpaying ccto ccthe ccprovider ccat ccthe cctime ccof ccservice. ccCopays ccare ccmostly
ccused ccfor ccoffice ccvisits ccto ccthe ccPCP, ccspecialist, ccUrgent ccCare, ccand ccER, ccbut
cconly ccif ccthe ccplan ccis ccdesigned ccwith cca cccopay ccoption.
Coinsurance cc- ccAnswer ccThe ccpercentage ccof cccosts ccshared ccby ccthe ccpatient ccand
ccthe ccinsurance ccplan cctypically ccafter ccthe ccmember's ccdeductible ccis ccmet. ccThese
ccamounts cccan ccvary ccbased ccon ccutilizing ccan ccINN ccprovider ccvs. ccOON ccprovider.
ccProviders cccan ccask ccfor ccthe ccmembers ccportion ccto ccbe ccpaid ccat ccthe cctime ccof
ccservice, ccbut ccsometimes ccis ccdeferred ccby ccthe ccprovider's ccoffice ccuntil ccthe ccclaim
cchas ccbeen ccprocessed ccand ccthe ccexact ccamount ccidentified.
OOP ccMAX cc(Out-of-Pocket ccMaximum) cc- ccAnswer ccThe cctotal ccmaximum ccamount
ccthat cca cccovered ccmember ccof ccfamily ccmember ccis ccresponsible ccfor ccpaying ccout-
of-pocket cctowards ccmedical ccservices ccwithin cca cccalendar ccor ccplan ccyear. ccThe
ccout-of-pocket cc(OOP) ccexpense ccusually ccincludes ccthe ccplan ccdeductible, ccwhat
ccthe ccmember ccpays ccfor ccco-insurance, ccand cc(if ccapplicable) cccopays. ccOnce ccthe
ccOOP ccMaximum cchas ccbeen ccmet, ccthe ccplan ccwill cccover cc100% ccof ccallowable
ccmedical ccexpenses ccby ccan ccINN ccprovider ccfor ccthe ccrest ccof ccthe cccalendar ccor
ccplan ccyear.
, Exclusions cc- ccAnswer ccHealthcare ccservices ccthat ccare ccnot cccovered ccby ccthe
ccplan.
Benefit ccLimitations/Maximums cc- ccAnswer ccWhen cclimitations ccare ccapplied ccto cca
ccplan, ccthe ccplan ccwill ccnot ccpay ccbenefits cconce ccthe cclimitations ccis ccreached, ccor
ccthe cccriteria ccis ccnot ccmet. cc(Example: cc"Covers cc60 ccvisits ccper ccplan ccyear ccfor
ccphysical, ccoccupational, ccand ccspeech cctherapy cccombined.")
Allowed ccAmount cc(Network ccContracted ccRate) cc- ccAnswer ccThe ccmaximum
ccamount cca ccprovider ccwill ccbe ccpaid ccfor cca ccservice. ccThe ccrate ccis ccbased ccon
cctheir cccontract ccwith ccthe ccnetwork. ccBenefits ccare ccpaid ccagainst ccthe cc"allowed
ccamount" ccnot ccthe ccactual cc"charged ccamount." ccINN ccproviders cccannot ccbalance
ccbill ccmembers ccfor ccthe ccdifference ccbetween ccthe ccprovider's cccharged ccamount
ccand ccthe ccmaximum ccallowed ccamount ccfor cccovered ccservices. cc
If cca cccaller ccquestions ccwhat ccthe ccamount ccis ccprior ccto ccservice, ccwe ccdo ccnot
cchave ccaccess ccto ccthis ccprivate cccontract ccinformation ccand ccwould ccneed ccto
ccdirect ccthem ccback ccto cctheir ccprovider ccand/or ccnetwork ccrepresentative.
U cc& ccC cc(Usual cc& ccCustomary) cc- ccAnswer ccThe ccU cc& ccC ccamount ccis ccused
ccwhen ccmembers ccuse ccan ccOON ccprovider. ccThe ccamount ccthat ccthe ccbenefits ccare
ccpaid ccagainst ccis ccbased ccon ccan ccaverage ccof ccwhat ccproviders ccin cca ccgeographic
ccare cccharge ccfor ccthe ccsame ccmedical ccservice. ccOON ccproviders cccan ccbalance
ccbill ccmembers ccfor ccthe ccdifference ccbetween ccthe ccprovider's cccharged ccamount
ccand ccthe ccU cc& ccC ccamount.
If cca ccmember ccor ccprovider ccquestions ccthe ccamount ccprior ccto ccservice, ccwe ccare
ccunable ccto ccprovide ccthem ccwith ccthat ccexact ccamount.
Medicare ccAllowable cc- ccAnswer ccMedicare ccAllowable ccrates ccare ccused ccwhen
ccmembers ccuse ccan ccOON ccprovider. ccThe ccamount ccthat ccbenefits ccare ccpaid
ccagainst ccis ccbased ccon cca ccpercentage ccof ccthe ccrates ccthat ccare ccprovided ccby
ccMedicare. cc(Example: cc110% ccof ccMedicare ccAllowable- ccmeaning ccthe ccrate ccthat
ccbenefits ccwill ccpay ccagainst ccwill ccbe cc110% ccof ccthe ccMedicare ccfee ccschedule).
ccOON ccproviders cccan ccbalance ccbill ccmembers ccfor ccthe ccdifference ccbetween ccthe
cc"charged ccamount" ccand ccthe cc"Medicare ccAllowable" ccamount.
Balance ccBilling cc- ccAnswer ccWhen cca ccprovider ccbills ccyou ccfor ccthe ccdifference
ccbetween ccthe ccprovider's cccharge ccand ccthe ccmaximum ccallowed ccamount
cc(contracted ccrate). cc(Example: ccIf ccthe ccprovider's cccharge ccis cc$100 ccand ccthe
ccallowed ccamount ccis cc$70, ccthe ccdifference/balance ccis cc$30). ccINN ccproviders
cccannot ccbalance ccbill ccfor cccovered ccservices.
Eligibility cc- ccAnswer ccA cccritical ccpiece ccof ccinformation ccthat cctells ccus ccwho ccis
cccovered, ccunder ccwhich ccplan, ccand ccduring ccwhat cctime ccframe. ccMany ccitems cccan
