Scenario #1

Sam Jones was seen by his primary care physician for an office visit.

Total Charges

$90.00

Contract Write-Off

$10.00

Insurance Company Paid

$64.00

Patient Responsibility

?

What amount is the patient responsibility?

Group of answer choices

$6.00

$26.00

$36.00

$16.00

Sam Jones was seen by his primary care physician for an office visit.

Total Charges	$90.00
Contract Write-Off	$10.00
Insurance Company Paid	$64.00
Patient Responsibility	?

What does the contract write-off mean?

Group of answer choices

The provider is in-network and cannot collect this amount from the patient.

The provider is in-network and can collect this amount from the patient.

The provider is out-of-network and does not have to write-off the contracted amount.

Contract write-off means the patient has a deductible.

3. Using the information listed - what is the patient's coinsurance amount?

Group of answer choices

30%

70%

80%

90%

Scenario #2

PATIENT INFORMATION

Patient Name

Andy Jones

Patient DOB

6/13/2010

INSURANCE INFORMATION

Insurance Information

Blue Cross Blue Shield

Policy holder's name (if different than patient)

James Jones

Policy holder's DOB

8/22/xxxx

Policy holder's relationship to patient

Father

INSURANCE INFORMATION

Insurance Information

United Healthcare

Policy holder's name (if different than patient)

Jane Jones

Policy holder's DOB

02/14/xxxx

Policy holder's relationship to patient

Mother

Which insurance plan is Primary Insurance for Andy?

Group of answer choices

United Healthcare

Blue Cross Blue Shield

Scenario #2

PATIENT INFORMATION

Patient Name

Andy Jones

Patient DOB

6/13/2010

INSURANCE INFORMATION

Insurance Information

Blue Cross Blue Shield

Policy holder's name (if different than patient)

James Jones

Policy holder's DOB

8/22/xxxx

Policy holder's relationship to patient

Father

INSURANCE INFORMATION

Insurance Information

United Healthcare

Policy holder's name (if different than patient)

Jane Jones

Policy holder's DOB

02/14/xxxx

Policy holder's relationship to patient

Mother

Who is the Primary Insured?

Group of answer choices

James Jones

Jane Jones

Scenario #2

PATIENT INFORMATION

Patient Name

Andy Jones

Patient DOB

6/13/2010

INSURANCE INFORMATION

Insurance Information

Blue Cross Blue Shield

Policy holder's name (if different than patient)

James Jones

Policy holder's DOB

8/22/xxxx

Policy holder's relationship to patient

Father

INSURANCE INFORMATION

Insurance Information

United Healthcare

Policy holder's name (if different than patient)

Jane Jones

Policy holder's DOB

02/14/xxxx

Policy holder's relationship to patient

Mother

How did you did determine Andy's primary insurance plan?

Group of answer choices

The Birthday Rule - Jane's birthday falls first in the year.

The Birthday Rule - James's birthday falls last in the year.

The Birthday Rule - does not apply.

Scenario #3 - TUFTS Explanation of Benefits

Review the Explanation of Benefits for John Sample from TUFTS Health Plan.

What is the amount John Sample is responsible for after the insurance processed the claim?

Group of answer choices

$20.00

$41.41

$61.41

$246.61

Scenario #3 - TUFTS Explanation of Benefits

Review the Explanation of Benefits for John Sample from TUFTS Health Plan.

What is the amount Jane Doe, MD cannot charge to John Sample?

Group of answer choices

$23.59

$85.00

$20.00

$61.41

Scenario #3 - TUFTS Explanation of Benefits

Review the Explanation of Benefits for John Sample from TUFTS Health Plan.

The annual family out-of-pocket limit is $8000. What amount is left for the family to pay before reaching the annual out-of-pocket limit?

Group of answer choices

$351.18

$206.75

$7648.82

$293.25

Scenario #3 - TUFTS Explanation of Benefits

Review the Explanation of Benefits for John Sample from TUFTS Health Plan.

John Sample has a deductible to meet annual. What amount was applied to the patient's deductible for the electrocardiography?

Group of answer choices

$20.00

$41.41

$65.00

$185.00

Scenario #4 - Cigna Explanation of Benefits

Amy Anyone was seen in the local emergency room.

Cigna paid a portion of Amy Anyone's laboratory services. What percentage (%) of the services did Cigna pay for these services?

Group of answer choices

80%

90%

100%

0%

Scenario #4 - Cigna Explanation of Benefits

Amy Anyone was seen in the local emergency room.

The total charges for Amy Anyone's services were $782.91 of which $85.14 was listed as not covered. Why was this amount not covered?

Group of answer choices

The healthcare professional billed twice for the same service. You do not need to pay this amount because it is a duplicate.

The healthcare professional billed once for the same service. You do need to pay this amount.

The healthcare professional never billed the service and it is outside timely filing requirements.

The healthcare professional billed once for the same service and it is outside timely filing requirements.

Scenario #4 - Cigna Explanation of Benefits

Amy Anyone was seen in the local emergency room.

The EOB has a "see notes" column and lists a "A" in the column. What does the note for "A" say?

Group of answer choices

Thank you for using the Cigna healthcare out-of-network provider.

Thank you for using the Cigna healthcare preferred provider organization (PPO) network. This represents the amount you owe.

Thank you for using the Cigna healthcare out-of-network provider. This represents the amount you owe.

Thank you for using the Cigna healthcare preferred provider organization (PPO) network. This represents your savings, so you are not required to pay for this amount.

Scenario #5 - Providence Health Plans Explanation of Benefits

Joe Providence had a consultation and surgery on the same day. Providence Health Plans applied a portion to Joe's yearly deductible. How much was applied to his deductible?

Group of answer choices

$395.85

$20.00

$284.15

$135.00

Scenario #5 - Providence Health Plans Explanation of Benefits

What is Joe's annual deductible and out-of-pocket amounts?

Group of answer choices

$2,000 deductible and $395.85 out-of-pocket

$2,000 deductible and $4,000 out-of-pocket

$4,000 deductible and $395.85 out-of-pocket

$20.00 deductible and $396.85 out-of-pocket

Scenario #5 - Providence Health Plans Explanation of Benefits

How much did Providence Health Plans pay towards Joe's services?

Group of answer choices

$0.00

$20.00

$67.75

$415.85