Certified Application Counselor Practice Test

Which of the following is most likely to be considered an allowed amount?

1. The full billed charge by the provider

2. The negotiated rate between the insurer and provider

3. The sum of all claims filed within a year

4. Any amount deemed righteously charged by the provider

The correct answer is: The negotiated rate between the insurer and provider

The negotiated rate between the insurer and provider is considered the allowed amount because it reflects the agreed-upon payment that the insurer will provide for particular services. This rate is typically established through contracts between the insurer and healthcare providers, ensuring that both parties have a mutual understanding of the payment terms. In essence, this amount represents the maximum that the health plan will pay for a specific service and is critical for determining the out-of-pocket costs for patients. It is a standard practice for insurers to negotiate rates with providers to control costs and ensure fair compensation for medical services rendered. In contrast, the full billed charge by the provider may exceed this negotiated amount, and while it reflects what the provider initially charges, it does not represent the amount that the insurer will actually pay. Similarly, the sum of all claims filed within a year does not pertain to a specific service's reimbursement rate, and any amount deemed righteously charged by the provider is subjective and may vary widely without standardized agreements in place.