Test Your Billing Definitions and Terms Knowledge

Multiple Choice

1. What is the difference between co-pay and coinsurance?

a. They mean the same thing and used by insurance companies interchangebly

b. Coinsurance is a percentage and copay is a set amount

c. Copay is a percentage and coinsurance is a set amount

d. Coinsurance is the term used only for Medicare patients

2. What is the definition of UCR?

a. Utilization management program that performs external utilization review services

b. Prauthorizations that are required for outpatient services

c. Amounts commonly charged for a service within a particular geographic region

d. An employer managed healthcare plan

3. What does EDI stand for?

a. Employer Designated Insurer

b. External Data Integrity

c. Error on Data Insurance

d. Electronic Data Interchange

4. What is capitation?

a. Pre-established payments to providers for enrollees over a period of time, whether the patient is seen or not by the provider

b. Payment for services rendered by providers and based many times on Medicare fee schedules

c. Services that all inclusive for a procedure, typically 10, 30 or 90 days

d. Health insurance plans that include preventive services

5. What is the definition of "deductible"?

a. The amount the insurance company will pay before patient co-insurance benefits are calculated

b. A specific dollar amount set by the insurance company for each visit or medical service that is rendered

c. The amount the patient is financially responsible before an insurance policy provides payment

d. The amount the insurance company is financially responsible before before other benefits are paid

6. What is the name of the standard claim form used to submit physician office services to Medicare and other insurance payors?

a. UB04

b. CMS1250

c. CMS1500

d. HSA

7. What is an EOB?

a. A report with details the results of processing a claim or called an Explanation of Benefits

b. A report sent to the employer with details of employee benefits paid for the month or called Employer Out-of-Pocket Benefits

c. A managed care plan the provide benefits to subscribers from network providers and also called Exclusive Outpatient Benefits

d. A external review organization that reviews claims after processing for medical necessity or called External Overview Billing organization


What is RBRVS?

a. Program with the federal govenemnt to help pay Medicare premiums, deductibles and coinsurance and coinsurance for low monthly
          individuals who have Medicare Part A

b. A fixed fee to physicians for participating and contracting with an insurance payor for services provided to their subscribers

c. A managed care fee-for-service plan that includes prescription drugs

d. Payment system for reimbursement of physician practice expenses base on the physician work, practice expense and malpractice
          insurance expense

9. What is the definition of a TPA?

a. Company that provides health benefits claims administration, processes claims and other outsourcing services for self-insured companies

b. Healthcare program for active duty members of the military and their family members

c. Temporary disability insurance for illness and injuries for those people injured on the job

d. Temporary assistance for needy families available on a time-limited basis for children due to a parent’s death

10. What does COB mean?

a. Physicians coordinating with other providers or agencies services to be provided to patient

b. Prevents multiple insurance plans from paying benefits covered by other plans when the patient has more than one policy

c. Allows employees to continue healthcare coverage beyond the benefit termination date

d. Supplemental plans designed to cover costs not paid by Medicare


Dedicated to making positive changes in your life and career.