Medical Claims and Healthcare Coverage Flashcards
7 cards from real CCA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medical Claims and Healthcare Coverage flashcards as text
What does 'reasonable and customary' refer to in medical claims evaluation?
Answer: The typical range of fees charged for a service in a specific geographic area
Reasonable and customary (R&C) represents the prevailing fees charged for specific medical services in a particular geographic area, used as a benchmark to assess whether charges are appropriate.
Under HIPAA regulations, a claims adjuster can obtain a claimant's medical records:
Answer: With the claimant's written authorization or a valid legal process such as a subpoena
HIPAA requires a valid patient authorization or legal process such as a subpoena for the release of protected health information to third parties including insurance adjusters.
A 'peer review' in medical claims handling involves:
Answer: A qualified medical professional evaluating the appropriateness of another physician's treatment
Peer review involves a qualified medical professional assessing whether the treatment provided was medically necessary, appropriate for the diagnosis, and consistent with accepted clinical standards.
What is a medical lien in personal injury claims?
Answer: A healthcare provider's legal right to share in settlement proceeds for unpaid medical bills
A medical lien gives healthcare providers who treated an injury victim the legal right to be reimbursed from any settlement or judgment the patient receives for their injuries.
What is the significance of establishing 'causation' when evaluating a medical claim?
Answer: It establishes the connection between the incident and the claimant's medical condition or injury
Causation establishes whether the claimant's injury or medical condition was caused by or directly related to the insured incident, which is fundamental to determining coverage and liability.
An 'aggravation' of a pre-existing condition in claims handling means:
Answer: A prior condition was worsened by the incident, potentially creating additional compensable liability
Aggravation occurs when an incident makes a pre-existing condition worse than it otherwise would have been, and adjusters must evaluate the portion of disability attributable to the new incident.
What is the purpose of a 'life care plan' in serious injury claims?
Answer: To outline and project costs for all future medical and care needs of a catastrophically injured person
A life care plan, prepared by a certified specialist, documents all projected future medical, rehabilitative, and personal care needs along with their projected costs for catastrophically injured claimants.