Health Insurance Plans Quiz

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Study Notes

Health Maintenance Organization (HMO): A managed care plan that provides comprehensive medical care services on a prepaid basis, requiring members to choose a Primary Care Physician (PCP) and provider location from participating providers.
Preferred Provider Organization (PPO): A type of health plan that contracts with medical providers to create a network of participating providers, allowing members to visit any in-network physician or healthcare provider without a referral from a primary care physician.
Point-of-Service (POS) plan: A mix between an HMO and a PPO-style health insurance policy, allowing members to have more choices than with an HMO, with the option to select a primary care provider and potentially requiring a referral to see a specialist.
Exclusive Provider Organization (EPO) plan: A plan that allows members to use doctors and hospitals within the EPO network, but not outside the network, with no out-of-network benefits.

Medicare Supplement Insurance (Medigap) policy: Helps pay some of the health care costs that Original Medicare doesn't cover, such as copayments, coinsurance, and deductibles.
Modifier: Two-digit codes that add information or change the description of a service or procedure rendered, categorized into two levels (Level I and Level II).
Patient Responsibility (PR): The amount a patient is responsible for paying that is not covered by the insurance plan.
Primary Care Physician (PCP): The physician who provides initial care and coordinates additional care if necessary.
Explanation of Benefits (EOB): A statement that comes with the insurance company payment to the provider, explaining payment details, covered charges, write-offs, and patient responsibilities and deductibles.
Electronic Remittance Advice (ERA): An electronic version of an insurance EOB that provides details of insurance claim payments, formatted according to the 835 standard.

Fee For Service: Insurance where the provider is paid for each service or procedure provided, typically allowing patients to choose their provider and hospital, but often with higher deductibles and co-pays.
Fee Schedule: Cost associated with each CPT treatment billing code for a provider's treatment or services.
Group Health Plan (GHP): A means for one or more employers to provide health benefits or medical care for their employees (or former employees).
Capitation: A fixed payment paid per patient enrolled over a defined period of time, paid to a health plan or provider, covering the costs associated with the patient's health care services.
Authorization: When a patient requires permission from the insurance company before receiving certain treatments or services.

Clearinghouse: A service that transmits claims to insurance carriers.
Claim processing: Involves verifying the processing date, allowed amount, and patient responsibility, and determining whether the claim is partially or fully applied towards the deductible.

Time difference between India and EST is 10 hours 30 minutes.
There is a difference of 1 hour between each time zone in the USA.
Daylight Saving Time (DST) is a system of adjusting the official local time forward by one hour, typically in the summer months, and backward by one hour in the autumn months.