MA 105 Exam 1 Study Guide questions
with complete solutions
Deductible - correct answer ✔✔ a specific amount of money paid before policy benefits begin
Copay - correct answer ✔✔ the amount of money a managed care plan requires a patient to
pay in the office prior to being seen by a provider
Coinsurance - correct answer ✔✔ cost sharing requirement where the insured pays a
percentage of the fee
Exclusion - correct answer ✔✔ a service never covered within a health insurance policy
Preexisting - correct answer ✔✔ conditions existing and treated prior to the effective date of a
policy
Eligibility verification - correct answer ✔✔ check and confirm that a patient is a member of the
insurance plan and the provided identification number is correct
Premium - correct answer ✔✔ an amount of money that is usually paid monthly to keep a
policy in force.
claim adjudicator - correct answer ✔✔ an insurance claim representative
Daysheet - correct answer ✔✔ a record sheet used to record daily business transactions
, Ledger - correct answer ✔✔ a patient's financial accounting record
What are some other terms that are used to refer to an insured individual? - correct answer
✔✔ policy holder
subscriber
member
Describe the differences between the terms Preauthorization, Precertification, and
Predetermination. - correct answer ✔✔ Preauthorization determines if a procedure is covered
and medically necessary
Precertification is discovers whether a treatment (surgery, hospitalization, tests) is covered
under a patient contract
Guarantor - correct answer ✔✔ An individual who promises to pay a medical bill by signing an
agreement or by accepting treatment
Define the birthday rule - correct answer ✔✔ It indicates which parent has primary coverage for
a child; and is determined by the parent who's birthday comes first in the calendar year
What is an assignment of insurance benefits? - correct answer ✔✔ It allows the healthcare
provider to receive reimbursement directly from the insurance
a) The patient must sign an assignment of benefits statement which
What is the difference between a participating and non participating physician/provider? -
correct answer ✔✔ Participating providers contract with an insurance plan to render care to
beneficiaries and bills the third-party payer directly
Non par providers do not have a contract to accept an allowed amount. They may or may not
file a courtesy insurance claim. They may obtain full payment at the time of service.
with complete solutions
Deductible - correct answer ✔✔ a specific amount of money paid before policy benefits begin
Copay - correct answer ✔✔ the amount of money a managed care plan requires a patient to
pay in the office prior to being seen by a provider
Coinsurance - correct answer ✔✔ cost sharing requirement where the insured pays a
percentage of the fee
Exclusion - correct answer ✔✔ a service never covered within a health insurance policy
Preexisting - correct answer ✔✔ conditions existing and treated prior to the effective date of a
policy
Eligibility verification - correct answer ✔✔ check and confirm that a patient is a member of the
insurance plan and the provided identification number is correct
Premium - correct answer ✔✔ an amount of money that is usually paid monthly to keep a
policy in force.
claim adjudicator - correct answer ✔✔ an insurance claim representative
Daysheet - correct answer ✔✔ a record sheet used to record daily business transactions
, Ledger - correct answer ✔✔ a patient's financial accounting record
What are some other terms that are used to refer to an insured individual? - correct answer
✔✔ policy holder
subscriber
member
Describe the differences between the terms Preauthorization, Precertification, and
Predetermination. - correct answer ✔✔ Preauthorization determines if a procedure is covered
and medically necessary
Precertification is discovers whether a treatment (surgery, hospitalization, tests) is covered
under a patient contract
Guarantor - correct answer ✔✔ An individual who promises to pay a medical bill by signing an
agreement or by accepting treatment
Define the birthday rule - correct answer ✔✔ It indicates which parent has primary coverage for
a child; and is determined by the parent who's birthday comes first in the calendar year
What is an assignment of insurance benefits? - correct answer ✔✔ It allows the healthcare
provider to receive reimbursement directly from the insurance
a) The patient must sign an assignment of benefits statement which
What is the difference between a participating and non participating physician/provider? -
correct answer ✔✔ Participating providers contract with an insurance plan to render care to
beneficiaries and bills the third-party payer directly
Non par providers do not have a contract to accept an allowed amount. They may or may not
file a courtesy insurance claim. They may obtain full payment at the time of service.
