Health Plan Field Guide

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Practice scenarios

Last reviewed · Educational use only

Realistic situations for training a front desk or checking your own understanding. Pick an answer to see the explanation.

Score: 0 / 0 answered correctly

1. A patient's plan has a $1,500 deductible (nothing met) and 20% coinsurance. An in-network surgeon bills $4,000; the allowed amount is $2,500. What does the patient owe?

2. A patient goes to an in-network hospital for surgery. The anesthesiologist turns out to be out of network. What can the anesthesiologist bill the patient?

3. A family plan has an embedded $2,000 individual / $4,000 family deductible. Only one child has claims this year, totaling $6,000 allowed. How much of that goes to the deductible?

4. A child's parents are married and both cover the child. Parent A was born June 5, 1980; Parent B was born February 20, 1990. Whose plan is primary for the child?

5. A remittance shows CO-45 for $800 on an in-network claim. Who owes the $800?

6. An EPO member sees an out-of-network dermatologist for a routine visit, with no emergency and no approved exception. What does the plan pay?

7. Which of these counts toward an ACA plan's in-network out-of-pocket maximum?

8. A claim was rejected by the clearinghouse 20 days ago for an invalid member ID and was never corrected. The payer's timely filing limit is 90 days from the date of service, which was 85 days ago. What is the situation?

9. A 67-year-old still works full time at a company with 500 employees and is enrolled in Medicare Part B and the employer plan. Which pays first?

10. A patient on an HSA-qualified HDHP family plan has a $3,400 aggregate family deductible. Early in the year they get a $300 primary care sick visit. What do they owe?

Answer key with explanations
  1. A patient's plan has a $1,500 deductible (nothing met) and 20% coinsurance. An in-network surgeon bills $4,000; the allowed amount is $2,500. What does the patient owe?
    Answer: $1,700. $1,500 deductible + 20% of the remaining $1,000 ($200) = $1,700. The $1,500 between the charge and the allowed amount is written off.
  2. A patient goes to an in-network hospital for surgery. The anesthesiologist turns out to be out of network. What can the anesthesiologist bill the patient?
    Answer: Only in-network cost-sharing. Anesthesia is an ancillary service at an in-network facility under the No Surprises Act. The patient owes only in-network cost-sharing, and ancillary providers cannot use notice and consent to waive it.
  3. A family plan has an embedded $2,000 individual / $4,000 family deductible. Only one child has claims this year, totaling $6,000 allowed. How much of that goes to the deductible?
    Answer: $2,000. With an embedded deductible, the child stops at the $2,000 individual deductible and coinsurance starts. On an aggregate plan, the full $4,000 would apply first.
  4. A child's parents are married and both cover the child. Parent A was born June 5, 1980; Parent B was born February 20, 1990. Whose plan is primary for the child?
    Answer: Parent B's. The birthday rule uses month and day only. February 20 comes before June 5, so Parent B's plan is primary.
  5. A remittance shows CO-45 for $800 on an in-network claim. Who owes the $800?
    Answer: No one; the provider writes it off. CO means contractual obligation and CARC 45 means the charge exceeds the contracted amount. In-network providers cannot bill patients for it.
  6. An EPO member sees an out-of-network dermatologist for a routine visit, with no emergency and no approved exception. What does the plan pay?
    Answer: Nothing. EPOs and HMOs generally have no out-of-network benefits except for emergencies and protected situations. The patient owes the full charge.
  7. Which of these counts toward an ACA plan's in-network out-of-pocket maximum?
    Answer: Copays. Deductibles, copays and coinsurance for covered in-network care count. Premiums, balance bills and non-covered services never do.
  8. A claim was rejected by the clearinghouse 20 days ago for an invalid member ID and was never corrected. The payer's timely filing limit is 90 days from the date of service, which was 85 days ago. What is the situation?
    Answer: 5 days left to submit a clean claim. A rejected claim was never received by the payer, so it does not count as filed. Fix and resubmit now; keep the acceptance report as proof.
  9. A 67-year-old still works full time at a company with 500 employees and is enrolled in Medicare Part B and the employer plan. Which pays first?
    Answer: The employer plan. For people 65+ covered through current employment at an employer with 20 or more employees, the group plan is primary and Medicare is secondary.
  10. A patient on an HSA-qualified HDHP family plan has a $3,400 aggregate family deductible. Early in the year they get a $300 primary care sick visit. What do they owe?
    Answer: The full allowed amount, about $300 minus the network discount. HDHPs generally cannot pay for non-preventive care before the deductible is met (telehealth and some other exceptions apply). The patient pays the allowed amount, which counts toward the deductible.