QUESTION: 5

Allowable Charge

The Maximum amount the payer will reimburse for each procedure or service, according to the patients policy.
DRG system adapted for use by thirdparty payers to reimburse hospitals for inpatient care provided to nonMedicare beneficiaries (e.g. Blue Cross Blue Shield, commercial health plans, TRICARE); DRG assignment is based on intensity of resources.
See limiting charge; maximum fee a physician may charge.
Adopted by Medicare in 2008 to reimburse hospitals for inpatient care provided to Medicare beneficiaries; expanded original DRG system (based on intensity of resources) to add two subclasses to each DRG that adjusts Medicare inpatient hospital reimbursement rates for of mortality (ROM) (likelihood of dying); each subclass, in turn, is subdivided into four areas: (1) minor, (2) moderate, (3) major, (4) extreme.

Answer(s): C

QUESTION: 6

Ambulatory Surgical Center (ASC) includes State Licensed Medicare-certified supplier (not provider) of surgical healthcare services that must accept assignment on Medicare Claims.