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MNT II: Billing And Coding Questions And Answers 2024/2025 Solutions
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MNT II: Billing And Coding Questions And Answers 2024/2025 Solutions Health care provider or supplier agrees (or is required by law to accept the third party payer-approved amount as full payment for covered services and not to bill the client for any more than the deductible and coinsurance. ANS ...

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  • October 10, 2024
  • 11
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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MNT II: Billing And Coding Questions And Answers
2024/2025 Solutions
Health care provider or supplier agrees (or is required by law to accept the third party payer-approved
amount as full payment for covered services and not to bill the client for any more than the
deductible and coinsurance. ANS Accept Assignment


A group of care providers who give coordinate care and chronic disease management, and thereby
improve the quality of care patients get. The organization's payment is tied to achieving health care
quality goals and outcomes that result in cost saving. ANS Accountable Care Organization


The amount of money charged by the health care provider or supplier for a certain medical service or
supply. This amount is often more than the amount Medicare or third party payers approve. ANS
Actual charge


May also be known as a waiver of liability. A notice health care providers and suppliers are required
to give and have signed by Original Medicare when they believe that Medicare will not cover the
services or items and the person has no reason to know that Medicare will not cover these services or
items. If no ABN is not provided by provider, the Medicare insured does not have to pay but if he/she
signed an ABN for the service/item then they are responsible and Medicare does not have to pay.
ANS Advance Beneficiary Notice (ABN)


Generic term referring to the maximum fee that a third party will use to reimburse a provider for a
given service. ANS Allowable charge


A request by a beneficiary or a provider to have a review when health care services are denied based
on medical necessity or appropriateness, or improperly paid. ANS Appeal


A referral that has been submitted to the patient's insurance company for approval for the services
requested to be performed. ANS Authorization


Balance billing is the practice of billing a patient for charges not paid by his/her insurance plan
because the charges are in excess of covered amounts. Balance billing amount will often be charges
that are beyond the fee schedule or contract rate. ANS Balance Bill

, A person who is covered by the third party payer ANS Beneficiary


The specified period of time during which charges for covered services must be incurred in order to
be eligible for payment by a third party payer. ANS Benefit period


The reimbursement of health care providers (such as hospitals and physicians) on the basis of
expected costs for clinically-defined episodes of care. It has been described as a "middle ground"
between fee for service reimbursement (in which providers are paid for each service rendered to a
patient) and capitation (in which providers are paid a "lump sum" per patient regardless of how many
services the patient receives).
Bundled payments have been proposed in the health care reform debate in the United States as a
strategy for reducing health care costs. ANS Bundled Payment


A payment arrangement for health care service providers based on a set amount for enrolled persons
assigned to them rather than a payment per service provided. The provider is paid whether or not the
enrolled person seeks care. ANS Capitation


A payment system that measures the intensity of care and services required for each patient, and
translates these measures into the amount of reimbursement given to the facility for care of a patient.
Payment if linked to the intensity of resource use. ANS Case Mix Reimbursement System


An electronic list of a facility's services and supplies, billing codes and the associated charges. The
charge master must be kept updated to the latest codes and government billing regulations for health
claims. ANS Charge Master



A request for payment for the service(s) provided by a health care provider. ANS Claim


The 1500 claim form is the universal insurance claim form developed and approved by the AMA and
Centers for Medicare and Medicaid Services. This form is used by non-institutional
providers/suppliers to bill Medicare carriers, commercial/private insurance and billing of some
Medicaid State Agencies. ANS 1500 Claim Form

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