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Health Insurance and Claims Chapter 11- 13

The legal business name of the practice is called what? The billing entity
Supplemental insurance plans designed by the federal government but sold by private commercial insurance companies to "cover the gaps in Medicare." Medigap
What occurs when a physician in the community refers a patient to the hospital for observation, bypassing the clinic or emergency department (ED). direct admission
One charge covers presurgical evaluation and management, initial and subsequent hospital visits, surgical procedure, the discahrg visit, and uncomplicated postop follow-up care in the surgeon's office. global fee/global surgery package
What is a secondary insurance plan called? It usually covers the deductible and copay or coinsurance of the primary health insurance policy. supplemental plan
a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further tx as hosp inpatients or be discharged. observation care
Are postoperative complications requiring a returnt ot he operating room for surgery related to the original procedure billed as an additional procedure or are they part of the global surgery package? They are billed as an additional procedure.
What are pica type, Courier 10 or OCR10? When you submit a typewritte claim you must use one of those font types.
Are you allowed to submit a photocopy of a CMS-1500 claim form? No, because they cannot be optically scanned.
Should handwritten notes, printed material, or special stamps be on a CMS-1500 form? No, they should be placed on an attachment to the claim.
What is an NPI? It is a unique 10-digit number issued to individual providers.
Is submission of an NPI required on a CMS-1500 claim to large or small health plans? It was required for both, effective May 23, 2008
What is assignment of benefits? It is when the patient instructs the payer to directly reimburse the provider for services rendered.
What does it mean to accept assignment? It is when the provider agrees to accept as payment in full whatever the payer reimburses.
If the payer accepts assignment it the patient still responsible for their deductible, copayment, and/or coinsruance? Yes
What is the maximum number of ICD-9 CM codes that you can put on a CMS-1500 claim? 4
What is the maximum number of CPT and/or HCPCS codes that you can put on a CMS-1500 claim? 6
The first-listed code reported should be what? The major reason the patient was treated.
If you report more than one CPT and/or HCPCS code does it matter what order you put them on the claim? Yes, you should enter the code with the highest fee in line 1 of Block 24, and then enter additional codes in descending order of charges.
EIN employer tax identification number
What is it called if a nonphysician practitioner in a group practice bills under their supervising physician? Incident to
Can outpatient observation care for a Medicare patient progress to an inpatient admission? Yes
Can an inpatient admission for a Medicare patient converted to outpatient observation care? No
What are the three ways to document that a patient has authorized the release of any medical or other information necessary to process their claim in Block 12 of the CMS-1500 claim? 1. They can sign the form in Block 122. The Billing Specialist can type SIGNATURE ON FILE in Block 12.3. The Billing Specialist can type SOF in Block 12.
What BCBS program enables is members to obtain healthcare services while traveling or living in another BCBS Plan's service area to receive the benefits of their home Plan contract and to access local provider networks? BlueCard program
What BCBS plan is an employer-sponsored health plan program for federal employees? Federal Employee Health Benefits Program (FEHBP)
What is another name for the Federal Employee Health Benefits Program? Federal Employee Program (FEP)
Created by: Kcompleta