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Health Ins.Process

Everything you need to know to study for the Health Insurance Processing Test

Question	Answer
A conversion factor is mulitiplied by a relative value unit to arrive at a charge.	TRUE
The medical insurance contract usually specifies the medical services it does not cover.	TRUE
The family deductible can be met by one individual member of the family.	TRUE
RVS is the abbreviation for relative volume scale.	FALSE
Commerical databases show ranges of provider's fees for various procedures nationwide.	TRUE
Some capitation contracts assign a different rate for each category of plan member.	TRUE
Most copayments are collected by physician practices at the time of service.	TRUE
Paper claims are usually created using a patient billing program,printed,and mailed to payers.	TRUE
A claim scrubber is used in hospital wards.	FALSE
A referring provider transfers patient care to another provider.	TRUE
A taxonomy code is used for federal tax returns.	FALSE
The parts of a patient's name -- first,middle,last--are examples of data elements.	TRUE
Billing programs often store a taxonomy-code database.	TRUE
The subscriber is never the same person as the patient.	FALSE
On a HIPAA claim,each service line has a procedure and a charge,at the minimum.	TRUE
The claim control number and the line item control number are both used to track payments from the health plan.	TRUE
Clean claims have proper HIPAA content.	TRUE
Accounts receivable include monies owed to a practice by both payers and patients.	TRUE
The day sheet in a medical office summarizes all the charges and payments from the start of the month to the current date.	FALSE
An aging report groups unpaid claims or bills according to the length of time that they remain due,such as 30 or 60 days.	TRUE
A retention schedule is a log of how long policyholders have been patients of a particular practice.	FALSE
Overpayments from Medicare to providers do not have to be paid back.	FALSE
HIPAA compliance records must be retained for six years.	TRUE
A carve out may be used by an employer to omit a specific benefit covered under a standard plan.	TRUE
Elective surgery and emergency surgery have the same approval requirements in most insurance plans.	FALSE
COBRA benefits must be extended to terminated employees for 24 months.	FALSE
Fiscal intermediaries for the Medicare program process Part B claims.	FALSE
LCDs are sent to patients by the Medicare program to explain new services or procedures.	FALSE
Outpatient surgeries are covered under Medicare Part A.	FALSE
Outpatient surgeries are covered under Medicare Part B.	TRUE
Supplemental insurance plans for Medicare beneficiaries provide additional coverage for an individual receiving benefits under Medicare Part A.	FALSE
Medicare provides benefits for urgently needed care even if the treatment is provided out of a plan's service area.	TRUE
ABN is the abbreviation for absolute beneficiary notification.	FALSE
Roster billing applies to Part A claims.	FALSE
FMAP is the basis for federal government Medicaid allocations to individual beneficiaries.	FALSE
Under the Medicaid program,medically indigent and medically needy have the same meaning.	TRUE
Under the Medicaid program,medically needy describes people with high medical expenses and low financial resources who are not receiving cash assistance.	TRUE
Under the Medicaid program,comprehensive health insurance coverage and free prescriptions are offered to pregnant women whose family income is below 133 percent of the poverty level.	FALSE
CHAMPVA is the abbreviation for Civilian Health and Medical Program of the Veterans Administration.	TRUE
DEERS is the abbreviation for Defense Emergency Entry System.	FALSE
Military Treatment Facilities are government hospitals and clinics whose first priority is to serve active-duty military personnel.	TRUE
NAS is the abbreviation for nonavailability statement.	TRUE
FECA is the abbreviation for Federal Employees' Compensation Act.	TRUE
A final report must be filed by providers in disability cases.	TRUE
In workers's compensation cases, a final report must be filed before the patient can return to work.	TRUE
Progress reports must be filed in disability compensation cases.	TRUE
SSDI is the abbreviation for the Socail Security Diagnosis Incidence program.	FALSE
Comorbidities are reported on hospital insurance claims whether or not these coexisiting conditions affect the patient's hospital stay.	TRUE
HIM is the abbreviation for health information management.	TRUE
Skilled nursing facilities specialize in offering outpatient services.	FALSE
The RBRVS fees are usually _____than UCR fees. a:lower b:the same c:higher d:none of the above	A: lower
Under RBRVS,the nationally uniform relative value is based on a:the geographic adjustment factor b:the uniform conversion factor c:the provider's work,practice cost,and malpractice insurance costs d:the UCR,practice cost,and malpractice insurance costs	C: the provider's work,practice cost,and malpractice insurance costs.
The purpose of the GPCI is to account for a:regional differences in costs b:changes in the cost of living index c:differences in relative work values d:none of the above	A: regional differences in costs
Which answer correclty lists the main method(s) payers use to pay providers?a:allowed charges b:allowed charges,contracted fee schedule,and capitation c:contracted fee schedule and capitation d:capitation and retrospective payments	B: allowed charges,contracted fee schedule,and capitation
If a provider's charge is higher than the allowed amount, the provider's reimbursement is based on a:the amount billed b:the amount allowed	B: the amount allowed
If the provider's charge is lower than the allowed amount,the reimbursement is based on a: the amount billed b: the amount allowed	A: the amount billed
The Medicare allowed charge for a procedure is $150,and PAR provider's usual charge is $200. What amount must the provider write off? a:$150 b:$100 c:$50 d:$30	C: $50
The Medicare allowed charge is $240 and the PAR provider's usual charge is $600. What amount does the patient pay? a:$192 b:$48 c:$480 d:$120	B: $48
The deductibles,coinsurance,and copayments patients pay are called their a:excluded services b:out-of-pocket expenses c:capitation rate d:maximum benefit limit	B: out-of-pocket expenses
If a nonparticipating provider's usual fee is $600,the allowed amount is $300,and the balance billing is permitted,what amount is written off? a:$150 b:$480 c:$300 d:$0	D: $0
A physician practice that uses a billing service to send its claims is the a:destination payer b:referring provider c:billing provider d:pay-to-provider	D: pay-to-provider
On a HIPAA claim,which of these is assigned to a claim by the sender? a:claim control number b:line item control number c:either a or b d:neither a or b	A: claim control number
The provider who provides the procedure on a claim if other than the pay-to-provider is called the a:referring provider b:rendering provider c:billing provider d:primary provider	B: rendering provider
A physician's state license number is an example of a(n) a:primary identification number b:pay-to-provider c:secondary identification number d: none of the above	C: secondary identification number
A physician's state license number is an example of a(n) a:primary identification number b:pay-to-provider c:secondary identification number d: none of the above	C: secondary identification number
The payer's processing of claims is called a:determination b:adjudication c:reduction d:utilization	B:adjudication
A payer's automated claim edits may result in claim denial because of a:lack of eligibility for a reported service b:lack of medical necessity c:lack of required preauthorization d:any of the above	D: any of the above
When a claim is pulled by a payer for a manual review, the provider may be asked to submit a:revised procedure codes b:a new diagnosis c:clinical documentation d:revised charges	C: clinical documentation
If a provider has accepted assignment,the payer sends the RA to a:the provider b:the patient c:the billing service d:the carrier	A: the provider
If the provider has not accepted assignment,the payer sends the payment to a:the provider b:the patient c:the billing service d:the carrier	B: the patient
The advantage(s) of EFT for practices is (are) a:funds are available immediately b:the transfer is less costly than check deposits c:neither a nor b d: both a and b	D: both a and b
What document is used by the medical insurance specialist to update the patient billing program with the payer's payments and the amount due from the patient? a:EFT b:RA c:IRA d:OIG	B: RA
Which of these HIPAA transactions is used by medical offices to ask payers about the status of submitted claims? a:835 b:837 c:276 d:277	C: 276
Which of these HIPAA transactions is sent by a payer to answer a question about a submitted claim? a:835 b:837 c:276 d:277	D:277
Which of these HIPAA transactions is sent by a payer to explain a claim payment? a:835 b:837 c:276 d:277	A:835
The federal law that protects companies which set up employee health and pension plans is known as? a:FEHBP b:CMS c:ERISA d:MCO	C: ERISA
The health insurance program for federal government employees is a:FEHBP b:ERISA c:HCFA d:BEDOR	A:FEHBP
Eligible members of a capitated plan are listed on the a:patient medical record b:monthly enrollment list c:annual membership list d:none of the above	B: monthly enrollment list
The terms of an insurance contract can be modified in a a:stop-loss provision b:section guideline c:rider d:provider withold	C:rider
Stop-loss provisions protect providers against a:malpractice charges b:extreme financial loss c:loss of number of patients d:increases in premiums	B:extreme financial loss
Which section of a managed care participation contract covers balance-billing rules? a:introductory section b:managed care plan obligations c:physician's responsibilities d: compensation and billing guidelines	D:compensation and billing guidelines
Which section of a managed care participation contract covers referrals and preauthorization rules? a:introductory section b:managed care plan obligations c:physician's responsibilities d:compensation and billing guidelines	C:physician's responsibilities
A plan pays 50 percent of the provider's usual charge and requires the copayment of $5 to be applied toward the provider's payment. What does the plan pay the provider when the usual charge is $200? a:$145 b:$95 c:$45 d:none of the above	B:$95
What percentage of the fee on the Medicare Fee Schedule is the limiting charge? a:115 percent b:100 percent c:85 percent d:80 percent	A: 115 percent
Anyone over age 65 who receives Social Security benefits is automatically a:enrolled in Medicare Part A b: eligible for Medicare Part B c:both a and b d: neither a nor b	C: both a and b
People who are over age 65 who do not receive Social Security benefits may enroll in Medicare Part A by a:paying a deductible b:paying a premium c:paying into a Medical Savings Account d:enrolling in a Medicare HMO	B: paying a premium
Under the Medicare program,if the approved amount for a procedure is $100,the participating physician will be paid $100(by Medicare and the patient),and the nonparticipant who accepts assignment will be paid a:$115 b:$100 c:$95 d:$80	C:$95
If a Medicare PAR physician thinks that a planned procedure will not be found medically necessary by Medicare and so will not be reimbursed,the patient is asked to sign a a:advance beneficiary notice b:notice of exclusions from Medicare benefits c:Medicar	A: Advance beneficiary notice
If a Medicare PAR physician knows that a planned procedure (such as a screening test) is not covered under Medicare and so will not be reimbursed,the patient is asked to sign a a:advance beneficiary notice b:notice of exclusions from Medicare benefits c:M	B:notice of exlusions from Medicare benefits
The TRICARE program that offers an HMO-like plan requiring no annual deductible is a:TRICARE Standard b:TRICARE Prime c:TRICARE Extra d:none of the above	B:TRICARE Prime
The TRICARE program that offers an alternative managed care plan to TRICARE Prime with no annual enrollment fee is a:TRICARE Standard b:TRICARE Extra c:CHAMPUS d:CHAMPVA	B:TRICARE Extra
When a provider initially examines a worker's compensation patient,what document must be filed with the state? a:final report b:admission of liability c:first report of injury d:vocational report	C:first report of injury
Social Security Disability Insurance provides compensation for lost wages to individuals who a:are qualified for welfare programs b:have contributed to Social Security c:either a or b d: neither a nor b	B:have contibuted to Social Security
Which term describes the patient's condition upon hospital admission? a:inpatient b:principal diagnosis c:admitting diagnosis d:principal procedure	C: admitting diagnosis
Which term describes the patient's condition that,after study,is established as the main reason for a hospital admission? a:inpatient b:principal diagnosis c:principal procedure d:admitting diagnosis	B: principal diagnosis
Which term describes the main service performed for the condition listed as the principal diagnosis for a hospital inpatient? a:primary procedure b:principal diagnosis c:admitting procedure d:principal procedure	D: principal procedure
Do stated Medicaid programs have to provide benefits for physician services?	YES
Do state Medicaid programs have to provide benefits for dental services?	NO
Do state Medicaid programs have to provide coverage for children's vaccines?	YES
Do state Medicaid programs have to provide coverage for experimental procedures?	NO
Do states offer both fee-for-service and managed care plans under Medicaid?	YES

Created by: mannj29

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