Insurance Policies & Contracts Flashcards
7 cards from real AAPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Insurance Policies & Contracts flashcards as text
A patient's insurance policy has a $500 deductible, 80/20 coinsurance, and a $3,000 out-of-pocket maximum. The patient has met $2,800 of their out-of-pocket maximum. For a $1,000 claim, what is the patient's liability?
Answer: $200 (remaining OOP max)
The patient needs only $200 more to reach their $3,000 out-of-pocket maximum, so liability is capped at $200.
Which contract term refers to the insurer's right to pursue a third party that caused an insurance loss to the insured?
Answer: Subrogation
Subrogation is the insurer's legal right to recover costs from a third party responsible for causing the insured's loss.
A commercial insurance contract requires the provider to submit claims within 90 days of the date of service. A claim submitted on day 95 is denied. This denial is based on:
Answer: Timely filing requirements
Timely filing denials occur when claims are submitted after the deadline specified in the provider contract.
Under a capitation agreement, a primary care physician receives $15 per member per month (PMPM). This payment model means the physician is paid:
Answer: A flat fee per enrolled member regardless of services used
Capitation pays a fixed amount per enrolled member per month, regardless of how many or how few services they actually use.
Which clause in an insurance policy explains what the insurer will NOT cover under any circumstances?
Answer: Exclusion clause
The exclusion clause specifically lists conditions, services, or circumstances that are not covered by the insurance policy.
A provider contract includes a 'most favored nation' clause. This means the provider must:
Answer: Offer that payer the lowest rate given to any other payer
A most favored nation clause requires the provider to give that payer rates at least as low as those offered to any other payer.
When a patient receives services from a non-participating provider in an HMO without a referral, the claim is typically:
Answer: Denied except for emergency services
HMO plans generally deny non-emergency services from non-participating providers seen without proper authorization or referral.