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chapter 09 insurance

QuestionAnswer
time limits stated in individual health insurance policies about an insurance company's obligation to pay benefits are the same for all insurance companies false
there is standardization of format for the explanation of benefit document for all private insurance carriers false
the insurance industry is protected by a special exemption from the federal trade commission true
insurance companies are rated according to the number of complaints received about them true
the status of electronic insurance claims may be accessed quickly electronically or telephonically by digital response systems true
inquires about insurance claims may be in writing or by telephone true
a rejected insurance claim should be corrected and sent in for review or appeal true
approximately 50% of individuals purse appeals on denied insurance claims false
in the case of a medicare part B redtermination, carriers have been instructed to pay an appealed insurance claim if the cost of the hearing process is more than the amount of the claim true
if you have a denied insurance claim, you should change the information and resubmit the claim false
routine use of too many nonspecific diagnostic codes may result in down coding true
In any type of over payment situation, always cash the third party check and write a refund check false
If a provider is notified by a commercial insurance carrier that a overpayment has been made, investigate the refund request true
a level 1 medicare redetermination (appeal) may be by telephone or in writing or by submitting a CMS-2007 Form true
a peer review is usually done before the appeal process false
appeal decisions on Medicare unassigned insurance claims are sent to the patient true
the highest level of a medicare redetermination is with an administrative law judge hearing false
If an insured is in disagreement with the insurer for the settlement of a claim, a suit must begin within 3 years
If a payment problem develops with an insurance company ignores claims and exceeds time limits to pay a claim, it is prudent to contact the state insurance commissioner
the document together with the payment voucher that is sent to the physician who has accepted assignment of benefits is referred to as a EOB
when receiving payment from a private insurance carrier, check the amount on the EOB with the copy of the CMS-1500 form
an insurance claims register provides a follow up procedure for insurance claims
pending or resubmitted insurance claims may be tracked through a tickler file
there are several ways to file pending insurance claims. What is the best way to file so that timely follow-up can be made file by patient's last name
a follow up effort made to an insurance company to locate the status of an insurance claim is called an inquiry and tracer
if an insurance claim has been lost by a insurance carrier the procedure to follow is ask if there is a backlog of claims, submit a copy of the original claim, and verify the correct mailing address
An example of a technical error on a insurance claim is duplicate dates of service, transposed numbers, missing place of service code
An insurance claim with an invalid procedure code would be rejected
what should you do if an insurance carrier requests information about another insurance carrier Provide the information
an insurance claim with an invalid procedure code would be rejected
an insurance claim for a service that has been bundled with other services would be denied
an insurance claim for which prior approval was not obtained would be denied
the total number of levels of redetermination that exist in the medicare program is 5
the first level of appeal in the medicare program is redetermination
the correct method to send documents for a medicare reconsideration (level 2) by certified mail with return receipt requested
a request for a medicare administrative law judge hearing can be made if the amount controversy is at least $130
How many levels of appeals for tricare 3
Tricare appeals are normally resolved in 60days
in a Tricare case, a request for an independent hearing may be pursed if the amount in question is 300 or more tricare
the total number of levels of redetermination that exist in the medicare program is 5
the first level of appeal in the medicare program is redetermination
the correct method to send documents for a medicare reconsideration (level 2) by certified mail with return receipt requested
a request for a medicare administrative law judge hearing can be made if the amount controversy is at least $130
How many levels of appeals for tricare 3
Tricare appeals are normally resolved in 60days
in a Tricare case, a request for an independent hearing may be pursed if the amount in question is 300 or more
an insured person cannot bring legal action against an insurance company until 60 days after a claim
documentation form private insurance carriers sent to participating providers that accompanies payment and describes the response to a claim is referred to by the acronym EOB
FTC Federal trade commission
Monitoring the activities of insurance companies and making sure that the interest of the policyholders are protected are the jobs of the insurance commission
all request of the insurance commissioner must be submitted in writing and include the patients signature
a delinquent insurance claim may be easily located by reviewing the insurance claim register
a suspense or follow-up file used to track pending insurance claims are called a tickler file
overdue payment on a insurance claim is referred to as delinquent claim
an insurance claim that is processed without following specific insurance carrier instructions is considered an rejected claim
if the medical practice receives payment from an insurance company that is more than the contract rate, it is called overpayment
Generally if a bill has not been paid, the physician rebills the patient every 30 days
If inadequate payment was received from an insurance company procedure, the insurance billing specialist should file an appeal on behalf of the physician
a request for a hearing before an administrative law judge( in a medicare case) may be made if the amount still in question is $130.00 or more
Created by: hudsondrummerman on 2013-08-06



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