NHA CBCS Module 2: Insurance
Eligibility and Other Payer Requirements
A child's mother and father have health coverage on the child, and there is a court order
stating the father is responsible for the child's health care. According to the birthday rule,
whose insurance would be primary?
A) Father
B) Mother - ANS-A) Father
The father's health insurance is primary according to court order, and the mother's health
insurance would be secondary.
\A patient falls off a ladder while at work. What type of insurance corresponds to the
scenario?
A) Homeowners insurance
B) Medical health plan
C) Workers' Compensation
D) Auto insurance - ANS-C) Workers' Compensation
Workers' Compensation covers an employee who is injured on the job.
\A patient falls off the roof while putting up holiday lights. What type of insurance
corresponds to the scenario?
A) Auto insurance
B) Homeowners insurance
C) Workers' Compensation
D) Medical health plan - ANS-B) Homeowners insurance
Homeowners insurance covers incidents on personal property.
\A patient is involved in a multi-vehicle accident. What type of insurance corresponds to the
scenario?
A) Workers' Compensation
B) Auto insurance
C) Medical health plan
D) Homeowners insurance - ANS-B) Auto insurance
Auto insurance covers the driver and/or passengers in vehicle accidents.
\A patient presents to the primary care office for a cough. What type of insurance
corresponds to the scenario?
A) Medical health plan
B) Workers' Compensation
C) Auto insurance
D) Homeowners insurance - ANS-A) Medical health plan
Medical health plans cover an individual's medical expenses.
, \A patient receives a gastric bypass surgery in March, and the yearly deductible has been
met by this claim. After the procedure, the maximum out-of-pocket amount has also been
met for the year. The patient presents to the office in June for joint injection that costs $2000.
If the coinsurance amount is 20%, which of the following amounts is the patient's
responsibility?
A) $0
B) $400
C) $1,600
D) $2,400 - ANS-A) $0
Because the out-of-pocket maximum has been met, the patient does not owe anything.
\According to Medicare, a patient who has diabetes mellitus should receive a hemoglobin
A1C blood test once every 3 months. More frequent testing should only be performed when
medically necessary. What modifier would be reported if the specialist does not obtain an
ABN prior to performing the service (modifiers listed in HCPCS)?
A) -GA
B) -GZ
C) -GY
D) -GX - ANS-B) -GZ
Modifier -GA is used when an ABN is signed and the claim form includes covered and
noncovered services. Modifier -GZ is reported when an ABN was not signed and the
services are expected to be not medically necessary. Modifier -GY identifies a service that is
statutorily excluded as a Medicare benefit. Modifier -GX is used when a voluntary ABN is
assigned for a statutorily noncovered service.
\Advance Beneficiary Notice of Noncoverage (ABN) - ANS-Documents (informed consent)
the beneficiary's decision about a service or procedure that Medicare may not cover. The
services and their cost must be reviewed with the patient prior to signing the ABN. Signing
the ABN doesn't mean that Medicare won't pay for a service, but just reassigns liability for it.
\automobile insurance - ANS-Protects the diver and passengers and pays for medical
expenses and other expenses (wage replacement, rental vehicles) related to an accident.
\birthday rule - ANS-Established by the NAIC and states:
-If the parents/guardians are married/living together, the caretaker with the earliest birthday
will be primary. If both caretakers have the same birthday, the caretaker who had the plan
the longest is the primary.
-A court order has authority to specify the primary plan of a child/dependent when both
caretakers have health insurance.
\capitation - ANS-An agreement with a provider to receive a pre-established payment for
health care services to enrollees over a period of time.
\coinsurance - ANS-Predetermined percentage the patient is responsible to pay for covered
services once the annual deductible has been met.
\Coordination of Benefits (COB) - ANS-Defines the order of responsibility for claims when
there is more than one payer. Determines which carrier is primary and which carrier is
secondary for a claim. Prevents duplicate payments, underpayments, or overpayments.
\copayment (copay) - ANS-Flat, fixed amount that a patient pays for specific services (e.g.,
office or emergency department encounters).
\covered benefits - ANS-Services outlined in the policy that are payable by the health plan.
Eligibility and Other Payer Requirements
A child's mother and father have health coverage on the child, and there is a court order
stating the father is responsible for the child's health care. According to the birthday rule,
whose insurance would be primary?
A) Father
B) Mother - ANS-A) Father
The father's health insurance is primary according to court order, and the mother's health
insurance would be secondary.
\A patient falls off a ladder while at work. What type of insurance corresponds to the
scenario?
A) Homeowners insurance
B) Medical health plan
C) Workers' Compensation
D) Auto insurance - ANS-C) Workers' Compensation
Workers' Compensation covers an employee who is injured on the job.
\A patient falls off the roof while putting up holiday lights. What type of insurance
corresponds to the scenario?
A) Auto insurance
B) Homeowners insurance
C) Workers' Compensation
D) Medical health plan - ANS-B) Homeowners insurance
Homeowners insurance covers incidents on personal property.
\A patient is involved in a multi-vehicle accident. What type of insurance corresponds to the
scenario?
A) Workers' Compensation
B) Auto insurance
C) Medical health plan
D) Homeowners insurance - ANS-B) Auto insurance
Auto insurance covers the driver and/or passengers in vehicle accidents.
\A patient presents to the primary care office for a cough. What type of insurance
corresponds to the scenario?
A) Medical health plan
B) Workers' Compensation
C) Auto insurance
D) Homeowners insurance - ANS-A) Medical health plan
Medical health plans cover an individual's medical expenses.
, \A patient receives a gastric bypass surgery in March, and the yearly deductible has been
met by this claim. After the procedure, the maximum out-of-pocket amount has also been
met for the year. The patient presents to the office in June for joint injection that costs $2000.
If the coinsurance amount is 20%, which of the following amounts is the patient's
responsibility?
A) $0
B) $400
C) $1,600
D) $2,400 - ANS-A) $0
Because the out-of-pocket maximum has been met, the patient does not owe anything.
\According to Medicare, a patient who has diabetes mellitus should receive a hemoglobin
A1C blood test once every 3 months. More frequent testing should only be performed when
medically necessary. What modifier would be reported if the specialist does not obtain an
ABN prior to performing the service (modifiers listed in HCPCS)?
A) -GA
B) -GZ
C) -GY
D) -GX - ANS-B) -GZ
Modifier -GA is used when an ABN is signed and the claim form includes covered and
noncovered services. Modifier -GZ is reported when an ABN was not signed and the
services are expected to be not medically necessary. Modifier -GY identifies a service that is
statutorily excluded as a Medicare benefit. Modifier -GX is used when a voluntary ABN is
assigned for a statutorily noncovered service.
\Advance Beneficiary Notice of Noncoverage (ABN) - ANS-Documents (informed consent)
the beneficiary's decision about a service or procedure that Medicare may not cover. The
services and their cost must be reviewed with the patient prior to signing the ABN. Signing
the ABN doesn't mean that Medicare won't pay for a service, but just reassigns liability for it.
\automobile insurance - ANS-Protects the diver and passengers and pays for medical
expenses and other expenses (wage replacement, rental vehicles) related to an accident.
\birthday rule - ANS-Established by the NAIC and states:
-If the parents/guardians are married/living together, the caretaker with the earliest birthday
will be primary. If both caretakers have the same birthday, the caretaker who had the plan
the longest is the primary.
-A court order has authority to specify the primary plan of a child/dependent when both
caretakers have health insurance.
\capitation - ANS-An agreement with a provider to receive a pre-established payment for
health care services to enrollees over a period of time.
\coinsurance - ANS-Predetermined percentage the patient is responsible to pay for covered
services once the annual deductible has been met.
\Coordination of Benefits (COB) - ANS-Defines the order of responsibility for claims when
there is more than one payer. Determines which carrier is primary and which carrier is
secondary for a claim. Prevents duplicate payments, underpayments, or overpayments.
\copayment (copay) - ANS-Flat, fixed amount that a patient pays for specific services (e.g.,
office or emergency department encounters).
\covered benefits - ANS-Services outlined in the policy that are payable by the health plan.
