HIM 130 TEST 1 questions with
complete solutions
accounts receivable (A/R) - correct answer ✔✔ monies owed to a medical practice
adjudication - correct answer ✔✔ Health plan process of examining claims and determining
benefits
benefits - correct answer ✔✔ Health plan payment for covered services
capitation - correct answer ✔✔ Payment method in which a prepayment covers the providers
services to a plan member for a specified period of time.
certification - correct answer ✔✔ The recognition of a person demonstrating a superior level of
skill on a national test by an official organization.
coinsurance - correct answer ✔✔ The portion of charges that an insured person must pay for
health care services after payment of the deductible amount; usually stated as a percentage.
compliance - correct answer ✔✔ Actions that satisfy official guidelines and requirements.
consumer-driven health plan (CDHP) - correct answer ✔✔ Type of medical insurance that
combines a high deductible health plan with a medical savings plan that covers some out-of -
pocket expenses.
copayment - correct answer ✔✔ An amount that a health plan requires a beneficiary to pay at
the time of service for each health care encounter.
,covered services - correct answer ✔✔ Medical procedures and treatments that are included as
benefits under an insured's health plan.
deductible - correct answer ✔✔ An amount that an insured person must pay, usually on an
annual basis, for health care services before a health plan's payment begins.
diagnosis code - correct answer ✔✔ The number assigned to a diagnosis in the International
Classification of Diseases.
ethics - correct answer ✔✔ Standards of conduct based on moral principles.
etiquette - correct answer ✔✔ Standards of professional behavior.
excluded services - correct answer ✔✔ A service specified in a medical insurance contract that
is not covered.
fee-for-services - correct answer ✔✔ Method of charging under which a provider's payment is
based on each service performed.
health care claim - correct answer ✔✔ An electronic transaction or a paper document filed with
a health plan to receive benefits.
health maintenance organization - correct answer ✔✔ A managed health care system in which
providers agree to offer health care to the organization's members for fixed periodic payments
from the plan; usually members must receive medical services only from the plan's providers.
health plan - correct answer ✔✔ Under HIPPA, an individual or group plan that either provides
or pays for the cost of medical care; includes group health plans, health insurance issuers,
, health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other
government and nongovernment plans.
indemnity plan - correct answer ✔✔ Type of medical insurance that reimburses a policyholder
for medical services under the terms of its schedule of benefits.
managed care - correct answer ✔✔ System that combines the financing and the delivery of
appropriate , cost-effective health care services to its members.
managed care organization (MCO) - correct answer ✔✔ Organization offering some type of
managed health care plan.
medical coder - correct answer ✔✔ Medical office staff member with specialized training who
handles the diagnostic and procedural coding of medical records.
medical insurance - correct answer ✔✔ Financial plans that covers the cost of hospital and
medical care.
medical insurance specialist - correct answer ✔✔ Medical office administrative staff member
who handles billing, checks insurance, and processes payments.
medical necessity - correct answer ✔✔ Payment criterion of payers that requires medical
treatments to be clinically appropriate and provided in accordance with generally accepted
standards of medical practice. To be medically necessary, the reported procedure or service
must match the diagnoses, be provided at the appropriate level, not be elective, not be
experimental, and not be performed for the convenience of the patient or the patient's family.
network - correct answer ✔✔ A group of providers having participation agreements with a
health plan. Using in-network providers is less expensive for the plan's enrollees.
complete solutions
accounts receivable (A/R) - correct answer ✔✔ monies owed to a medical practice
adjudication - correct answer ✔✔ Health plan process of examining claims and determining
benefits
benefits - correct answer ✔✔ Health plan payment for covered services
capitation - correct answer ✔✔ Payment method in which a prepayment covers the providers
services to a plan member for a specified period of time.
certification - correct answer ✔✔ The recognition of a person demonstrating a superior level of
skill on a national test by an official organization.
coinsurance - correct answer ✔✔ The portion of charges that an insured person must pay for
health care services after payment of the deductible amount; usually stated as a percentage.
compliance - correct answer ✔✔ Actions that satisfy official guidelines and requirements.
consumer-driven health plan (CDHP) - correct answer ✔✔ Type of medical insurance that
combines a high deductible health plan with a medical savings plan that covers some out-of -
pocket expenses.
copayment - correct answer ✔✔ An amount that a health plan requires a beneficiary to pay at
the time of service for each health care encounter.
,covered services - correct answer ✔✔ Medical procedures and treatments that are included as
benefits under an insured's health plan.
deductible - correct answer ✔✔ An amount that an insured person must pay, usually on an
annual basis, for health care services before a health plan's payment begins.
diagnosis code - correct answer ✔✔ The number assigned to a diagnosis in the International
Classification of Diseases.
ethics - correct answer ✔✔ Standards of conduct based on moral principles.
etiquette - correct answer ✔✔ Standards of professional behavior.
excluded services - correct answer ✔✔ A service specified in a medical insurance contract that
is not covered.
fee-for-services - correct answer ✔✔ Method of charging under which a provider's payment is
based on each service performed.
health care claim - correct answer ✔✔ An electronic transaction or a paper document filed with
a health plan to receive benefits.
health maintenance organization - correct answer ✔✔ A managed health care system in which
providers agree to offer health care to the organization's members for fixed periodic payments
from the plan; usually members must receive medical services only from the plan's providers.
health plan - correct answer ✔✔ Under HIPPA, an individual or group plan that either provides
or pays for the cost of medical care; includes group health plans, health insurance issuers,
, health maintenance organizations, Medicare Part A or B, Medicaid, TRICARE, and other
government and nongovernment plans.
indemnity plan - correct answer ✔✔ Type of medical insurance that reimburses a policyholder
for medical services under the terms of its schedule of benefits.
managed care - correct answer ✔✔ System that combines the financing and the delivery of
appropriate , cost-effective health care services to its members.
managed care organization (MCO) - correct answer ✔✔ Organization offering some type of
managed health care plan.
medical coder - correct answer ✔✔ Medical office staff member with specialized training who
handles the diagnostic and procedural coding of medical records.
medical insurance - correct answer ✔✔ Financial plans that covers the cost of hospital and
medical care.
medical insurance specialist - correct answer ✔✔ Medical office administrative staff member
who handles billing, checks insurance, and processes payments.
medical necessity - correct answer ✔✔ Payment criterion of payers that requires medical
treatments to be clinically appropriate and provided in accordance with generally accepted
standards of medical practice. To be medically necessary, the reported procedure or service
must match the diagnoses, be provided at the appropriate level, not be elective, not be
experimental, and not be performed for the convenience of the patient or the patient's family.
network - correct answer ✔✔ A group of providers having participation agreements with a
health plan. Using in-network providers is less expensive for the plan's enrollees.
