HFMA CRCR EXAM | PRACTICE
QUESTIONS AND ANSWERS | GRADED
AND RATED A+ | 2024/2025 GUIDE
Health plan
- Correct Answer - an insurance company that provides for the
delivery or payment of healthcare services
Indemnity insurance
- Correct Answer - negotiated healthcare coverage within a
framework of fee schedules, limitations, and exclusions that is
offered by insurance companies or benevolent associations
Medically necessary
- Correct Answer - Healthcare services that are required to
preserve or maintain a person's health status in accordance with
medical practice standards
Out-of-area benefits
,- Correct Answer - healthcare plan coverage allowed to covered
persons for emergency situations outside of the prescribed
geographic area of the HMO
Out-of-pocket payments
- Correct Answer - Cash payments made by the insured for
services not covered by the health insurance plan
Pre-admission review
- Correct Answer - the practice of reviewing requests for inpatient
admission before the patient is admitted to ensure that the
admission is medically necessary
Pre-existing condition limitation
- Correct Answer - A restriction on payments for charges directly
resulting from a pre-existing health conditions
Same-day admission
- Correct Answer - A cost containment practice that reduces a
surgical patient's inpatient stay by requiring that pre-procedure
testing and preparation are completed on an outpatient basis and
the patient is admitted the same day as the procedure
,Self-insured
- Correct Answer - Large employers who assume direct
responsibility or risk for paying employees' healthcare without
purchasing health insurance
Subrogation
- Correct Answer - Seeking, by legal or administrative means,
reimbursement from another party that is primarily responsible for
a patient's medical expenses
Subscriber
- Correct Answer - An employer, a union, or an association that
contracts with an insurance company for the healthcare plan it
offers to eligible employees
Sub-specialist
- Correct Answer - A healthcare professional who is recognized to
have expertise in a specialty of medicine or surgery
Third-part administrator (TPA)
- Correct Answer - Provides services to employers or insurance
companies for utilization review, claims payment and benefit
design
, Third-party reimbursement - Correct Answer - A general term
used for the healthcare benefit payments - used to identify that for
benefit plans there are three parties in the transaction
Usual, customary, and reasonable (UCR) - Correct Answer -
Health insurance plan reimbursement methodology that limits
payment to the lower billed charges, the provider's customary
charge, or the prevailing charge for the service in the community
Utilization review - Correct Answer - Review conducted by
professional healthcare personnel of the appropriateness of,
quality of, and need for healthcare services provided to patients
Charge - Correct Answer - The dollar amount a provider sets for
services rendered before negotiating any discounts. The charge
can be different from the amount paid
Cost - Correct Answer - The definition of cost varies by party
incurring the expense
Price - Correct Answer - the total amount a provider expects to be
paid by payers and patients for healthcare services
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