Everything you need to know to study for the Health Insurance Processing Test
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| A conversion factor is mulitiplied by a relative value unit to arrive at a charge. | TRUE
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| The medical insurance contract usually specifies the medical services it does not cover. | TRUE
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| The family deductible can be met by one individual member of the family. | TRUE
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| RVS is the abbreviation for relative volume scale. | FALSE
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| Commerical databases show ranges of provider's fees for various procedures nationwide. | TRUE
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| Some capitation contracts assign a different rate for each category of plan member. | TRUE
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| Most copayments are collected by physician practices at the time of service. | TRUE
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| Paper claims are usually created using a patient billing program,printed,and mailed to payers. | TRUE
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| A claim scrubber is used in hospital wards. | FALSE
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| A referring provider transfers patient care to another provider. | TRUE
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| A taxonomy code is used for federal tax returns. | FALSE
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| The parts of a patient's name -- first,middle,last--are examples of data elements. | TRUE
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| Billing programs often store a taxonomy-code database. | TRUE
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| The subscriber is never the same person as the patient. | FALSE
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| On a HIPAA claim,each service line has a procedure and a charge,at the minimum. | TRUE
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| The claim control number and the line item control number are both used to track payments from the health plan. | TRUE
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| Clean claims have proper HIPAA content. | TRUE
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| Accounts receivable include monies owed to a practice by both payers and patients. | TRUE
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| The day sheet in a medical office summarizes all the charges and payments from the start of the month to the current date. | FALSE
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| 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
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| A retention schedule is a log of how long policyholders have been patients of a particular practice. | FALSE
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| Overpayments from Medicare to providers do not have to be paid back. | FALSE
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| HIPAA compliance records must be retained for six years. | TRUE
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| A carve out may be used by an employer to omit a specific benefit covered under a standard plan. | TRUE
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| Elective surgery and emergency surgery have the same approval requirements in most insurance plans. | FALSE
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| COBRA benefits must be extended to terminated employees for 24 months. | FALSE
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| Fiscal intermediaries for the Medicare program process Part B claims. | FALSE
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| LCDs are sent to patients by the Medicare program to explain new services or procedures. | FALSE
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| Outpatient surgeries are covered under Medicare Part A. | FALSE
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| Outpatient surgeries are covered under Medicare Part B. | TRUE
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| Supplemental insurance plans for Medicare beneficiaries provide additional coverage for an individual receiving benefits under Medicare Part A. | FALSE
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| Medicare provides benefits for urgently needed care even if the treatment is provided out of a plan's service area. | TRUE
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| ABN is the abbreviation for absolute beneficiary notification. | FALSE
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| Roster billing applies to Part A claims. | FALSE
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| FMAP is the basis for federal government Medicaid allocations to individual beneficiaries. | FALSE
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| Under the Medicaid program,medically indigent and medically needy have the same meaning. | TRUE
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| Under the Medicaid program,medically needy describes people with high medical expenses and low financial resources who are not receiving cash assistance. | TRUE
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| 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
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| CHAMPVA is the abbreviation for Civilian Health and Medical Program of the Veterans Administration. | TRUE
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| DEERS is the abbreviation for Defense Emergency Entry System. | FALSE
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| Military Treatment Facilities are government hospitals and clinics whose first priority is to serve active-duty military personnel. | TRUE
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| NAS is the abbreviation for nonavailability statement. | TRUE
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| FECA is the abbreviation for Federal Employees' Compensation Act. | TRUE
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| A final report must be filed by providers in disability cases. | TRUE
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| In workers's compensation cases, a final report must be filed before the patient can return to work. | TRUE
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| Progress reports must be filed in disability compensation cases. | TRUE
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| SSDI is the abbreviation for the Socail Security Diagnosis Incidence program. | FALSE
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| Comorbidities are reported on hospital insurance claims whether or not these coexisiting conditions affect the patient's hospital stay. | TRUE
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| HIM is the abbreviation for health information management. | TRUE
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| Skilled nursing facilities specialize in offering outpatient services. | FALSE
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| The RBRVS fees are usually _____than UCR fees. a:lower b:the same c:higher d:none of the above | A: lower
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| 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.
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| The payer's processing of claims is called a:determination b:adjudication c:reduction d:utilization | B:adjudication
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| The health insurance program for federal government employees is a:FEHBP b:ERISA c:HCFA d:BEDOR | A:FEHBP
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| Which term describes the patient's condition upon hospital admission? a:inpatient b:principal diagnosis c:admitting diagnosis d:principal procedure | C: admitting diagnosis
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| 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
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| 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
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| Do stated Medicaid programs have to provide benefits for physician services? | YES
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| Do state Medicaid programs have to provide benefits for dental services? | NO
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| Do state Medicaid programs have to provide coverage for children's vaccines? | YES
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| Do state Medicaid programs have to provide coverage for experimental procedures? | NO
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| Do states offer both fee-for-service and managed care plans under Medicaid? | YES
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