CBCS Payer Types and Policies 2

Question 1

What is TRICARE and who is eligible for it?

Accepted Answer

The health care program for active-duty service members, retirees, and their families through the Department of Defense

Answer

TRICARE is the healthcare benefit for members of the uniformed services (active duty, National Guard/Reserve, retired) and their eligible family members, administered by the Department of Defense.

Question 2

What is a Medicare Administrative Contractor (MAC)?

Accepted Answer

A private company contracted by CMS to process Medicare fee-for-service claims in a specific geographic jurisdiction

Answer

MACs are private companies that serve as Medicare's claim processors in specific geographic regions (jurisdictions), handling Part A and Part B claims submission, payment, and audit functions.

Question 3

What is the Federal Employees Health Benefits (FEHB) Program?

Accepted Answer

The health benefits program for federal civilian employees, retirees, and their dependents, offering a choice of health plans

Answer

FEHB is the health benefits program for federal civilian employees and retirees, offering enrollment in a choice of approved health plans (fee-for-service, HMO, HDHP/HSA) administered by OPM.

Question 4

What is a self-funded (self-insured) employer health plan?

Accepted Answer

An employer that assumes financial responsibility for employee health claims rather than paying premiums to an insurance company; typically administered by a TPA

Answer

In a self-funded plan, the employer directly pays employee health claims from its own funds rather than buying insurance. A Third-Party Administrator (TPA) typically processes claims using the employer's money.

Question 5

What is Workers' Compensation insurance, and how does billing differ from standard health insurance?

Accepted Answer

Insurance that covers medical treatment and lost wages for employees injured on the job or who develop work-related illnesses; billing uses separate forms and diagnosis coding specific to the injury

Answer

Workers' compensation covers medical care and lost wages for work-related injuries/illnesses. Claims are billed to the employer's WC carrier using state-specific forms, focus only on the work injury, and follow different reimbursement rules than standard health insurance.

(CBCS) Certified Billing and Coding Specialist Practice Test

(CBCS) Certified Billing and Coding Specialist Practice Test

CBCS Payer Types and Policies 2