AAPC Insurance Policies & Contracts 2

Question 1

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?

Accepted Answer

$200 (remaining OOP max)

Answer

The patient needs only $200 more to reach their $3,000 out-of-pocket maximum, so liability is capped at $200.

Question 2

Which contract term refers to the insurer's right to pursue a third party that caused an insurance loss to the insured?

Accepted Answer

Subrogation

Answer

Subrogation is the insurer's legal right to recover costs from a third party responsible for causing the insured's loss.

Question 3

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:

Accepted Answer

Timely filing requirements

Answer

Timely filing denials occur when claims are submitted after the deadline specified in the provider contract.

Question 4

Under a capitation agreement, a primary care physician receives $15 per member per month (PMPM). This payment model means the physician is paid:

Accepted Answer

A flat fee per enrolled member regardless of services used

Answer

Capitation pays a fixed amount per enrolled member per month, regardless of how many or how few services they actually use.

Question 5

Which clause in an insurance policy explains what the insurer will NOT cover under any circumstances?

Accepted Answer

Exclusion clause

Answer

The exclusion clause specifically lists conditions, services, or circumstances that are not covered by the insurance policy.

(AAPC) American Academy of Professional Coders Biller Certified Practice Test

(AAPC) American Academy of Professional Coders Biller Certified Practice Test

AAPC Insurance Policies & Contracts 2