AAPC Insurance Policies & Contracts 3

Question 1

A provider who signs a participation agreement with Medicare must accept assignment, which means they agree to:

Accepted Answer

Accept Medicare's allowed amount as payment in full

Answer

Accepting assignment means the provider accepts Medicare's approved amount as full payment and cannot bill the patient more than applicable cost-sharing.

Question 2

The term 'allowed amount' in an insurance contract refers to:

Accepted Answer

The maximum the insurer will pay for a specific service

Answer

The allowed amount (also called the allowable or fee schedule amount) is the maximum reimbursement the payer will provide for a given service.

Question 3

Which type of insurance policy requires the insured to choose a primary care physician who manages all care and referrals?

Accepted Answer

HMO

Answer

Health Maintenance Organizations (HMOs) require members to select a PCP who acts as a gatekeeper and coordinates all referrals.

Question 4

A payer contract states that the provider cannot bill patients for the difference between the billed amount and the allowed amount. This is known as:

Accepted Answer

Balance billing prohibition

Answer

A balance billing prohibition in a provider contract prevents the provider from charging patients the difference between billed charges and the payer's allowed amount.

Question 5

Under a Point-of-Service (POS) plan, a member who sees an out-of-network provider without a referral will typically:

Accepted Answer

Pay higher cost-sharing compared to in-network care

Answer

POS plans allow out-of-network use but impose higher deductibles, coinsurance, or copays compared to in-network care.

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

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

AAPC Insurance Policies & Contracts 3