Insurance and Reimbursement Flashcards
7 cards from real RMA 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 and Reimbursement flashcards as text
A patient has both Medicare and Medicaid. Which is considered the primary payer?
Answer: Medicare
Medicaid is always the payer of last resort, so Medicare pays first.
What does the term 'coordination of benefits' (COB) refer to?
Answer: Determining the order in which multiple insurers pay
COB establishes which insurer is primary and which is secondary when a patient has more than one plan.
Under the 'birthday rule,' which parent's plan is primary for a dependent child?
Answer: The parent whose birthday falls earlier in the calendar year
The birthday rule makes primary the plan of the parent whose birthday comes first in the year.
What is an Explanation of Benefits (EOB)?
Answer: A statement from the insurer detailing what was paid and patient responsibility
The EOB documents the insurer's processing of a claim, including payments and patient responsibility.
A 'capitation' payment model reimburses a provider how?
Answer: A fixed amount per patient per month regardless of services
Capitation pays a set fee per enrolled patient per period, no matter how many services are used.
Which form is the standard claim form used for physician and outpatient services?
Answer: CMS-1500
The CMS-1500 is the standard paper claim form for physician and non-institutional outpatient services.
What is 'usual, customary, and reasonable' (UCR) charge?
Answer: A fee within the range commonly charged for a service in a geographic area
UCR reflects the typical fee charged for a service within a specific region.