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 provider contract includes a 'clean claim' definition requiring specific data elements. If a claim is missing a required element, the payer may:
Answer: Pend or deny the claim for additional information
Payers may pend or deny claims that do not meet the clean claim definition outlined in the provider contract, pending receipt of missing information.
When a patient has both a primary and secondary insurance plan, the secondary plan's payment is typically based on:
Answer: The patient's remaining liability after primary payment
The secondary payer processes claims based on the patient's remaining liability (deductible, coinsurance, copay) after the primary payer has processed the claim.
Which of the following best describes a 'carve-out' benefit in an insurance contract?
Answer: A benefit removed from the standard plan and managed separately
A carve-out separates a specific benefit (such as mental health or pharmacy) from the main health plan and administers it through a separate organization.
A provider contract's 'hold harmless' clause protects the patient from being billed when:
Answer: The payer becomes insolvent or fails to pay the provider
A hold harmless clause ensures patients cannot be billed by providers if the payer fails to reimburse, protecting patients from insurer insolvency.
An insurance policy's 'birthday rule' is used to determine primary coverage for a dependent child when:
Answer: Both parents carry insurance for the child
The birthday rule determines which parent's plan is primary when both parents cover a dependent child — the parent whose birthday falls first in the calendar year has the primary plan.
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA), a qualifying event that triggers continuation coverage includes:
Answer: An employee's voluntary resignation from employment
Voluntary resignation is a COBRA qualifying event that allows the employee to elect continuation of group health coverage for up to 18 months.
A provider participates in a Preferred Provider Organization (PPO). A PPO member who sees the provider will pay:
Answer: In-network cost-sharing rates as defined by the PPO plan
PPO members who use in-network (preferred) providers pay the reduced in-network cost-sharing amounts specified in their plan documents.