Medical Insurance

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Answer

The concept that every procedure or service reported to a third party payer must be linked to a condition that justifies the procedure or service is called:

Necessity

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Which is atypical responsibility of a health insurance specialist

Correcting claims processing errors

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The mutual exchange of infromation between providers and payer is called electronic

data interchange

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The document submitted by a provider to third party for the prupose of requesting reimbursement for services provided is a (an)

claim

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The process of classifying diagnoses, procedures, and services is called

coding

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Which coding system is used for reporting procedures and services in physicians's offices?

CP T

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Diagnoses are coded according to

ICD-9-CM

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Rules that govern the conduct of members of a profession are called

Ethics

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Physician offices should bond employees who have which responsibility?

Financial

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Which term is another word for stealing money?

embezzling

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A claim was submitted for a left shoulder xray on an elderly patient, and the diagnosis reported on the claim was urinary tract infection. The claim was rejected because

Medical necessity was not met

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The type of health care that helps individuals avoid health and injury problems is

Preventive

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Which is a government sposnored health program that provides benefits to low income patients?

Medicaid

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The standard claim developed by CMS and used to report procedures and services delivered by physicians is called the

CMS _1500

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The act passed in 1996 that has had a great impact on confidentiality, electroncic information transmission and standardization is the

HIPAA

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Which three componets constitute the RBRVS payment system?

Phyician work, practice expense, and malpractiece insurance expense

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Insurance that is available through employers , labor unions consumer health cooperatives and other organizations is

Group health insurance

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A provider's list of predetermined payments for healthcare services to patients is know as the

Fee Schedule

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Which term describes the process of developing patient care plans for hte coordination and provision of care for complicated cases in a cost effective manner?

Case management

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Mandates are:

Laws

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Employees and dependents who join a managed care plan are called

Subscribers

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Which act or amendment established an employees right to continue healthcare coverage beyond a scheduled benefit termination date

Cobra of 1985

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If a plan allows enrollees to seek care from non-network providers, what effect will this have on the enrollee who sees a non network provider? The enrollee will

pay highter out of pocket expenses

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The specified percentage or charges the patient must pay to the provider for each service received for for each visit is the

Coinsurance

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Data transmitted electronically or manually to payers or clearinghouses is called claims

Submission

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When the provider is required to receive as payment in full whaterver amount 6the insurance reimburses fro services, the provider is agreeing to

Accept Assignment

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The person responsible for paying ht echarges for services rendered by the provider is the

Guarantor

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Which document is used to generate the patient's financial and medical record?

Patient registration form

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The rule stating that the policyholder whose birth month and day occure earlier in hte calender year holds the primary policy for dependent children is the ______rule

Birthday

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The insurance industry is regulated by whom?

Individual States

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Federal and state statue are :

Passed by legislative bodies

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Breach of confidentiality can resuld from

Discussing patiend healtcare infomation with unauthorized sources

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The recognized difference between fraud and abuse is the

Intent

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Undated signed froms are sassumed to be valid until revoked by the patient or

Guardian

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when a Medicare provider commits fraud, which entity conducts the investigation?

Office of hte Inspector General

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The diagnositc statement"urinary tract infection due to E.Coli" require ___codes) to b eassigned

Two

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Which convention is used to display a series of terms that can modify the statement to its right

Braces

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In ICD-9-CM, italicized codes signify that

More thatn one code is required to fully describe a diagnosis

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Type 2 diabetic cataract , right ey

b. 250.50, 366.41

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The ICD-9=CM system classifies

Morbidity

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ICD-9CM's V codes classify

Factors influencing health status

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When reporting ctp codes on hte CMX-1500 claim, medical necessity is proven by

Linking hte CPT code to its ICD-9-CM Counter part

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A black triangle located to the left of a CP T code indicates that the code

Has been revised from previous CP T publications

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Intial office visit for a patien with left knee pain. Detailed history and expamination was documented, alon with low complexity medical decision makeing>

99203

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According to CPT, Prolonged services codes are assigned in addition to other E/M services when treatment exceeds the time included in the CPT description by ___Minutes

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HCPC is a multilevel coding system that contains ____ levels

two

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Which statement is true of durable medical equipment?

It can withstand repeated use

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Which special codes allow payer the flexibility of establishing codes if they are needed before the next January 1 annual update?

Temporary

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EWach realitive value componet is multiplied by the geographic cost practice index (GCPI ) and then each is further multiplied by a variable figure called the

Conversion factor

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Nonparticipating (nonpar) provider are restriced to billin at or below the

Limiting charge

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Medicare participating providers commonly report actual fees to Medicar ebut adjust fees after payment is receives> The difference between the fee reported and the payment received is a

Write-off

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Incident to relates to services provided by no Pars that ar edefined as services

Provide incidental to other services provide by a physician

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The prospective payment system dependent on hte patiens principal diagnosis comorbidities, complications, and principal and secondary procedures is called

Diagnosis -related groups (DRGs)

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What term is used to describe the types and categories of patients treated by a health care facility or provider

Case Mix

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The Medicare physician fee schedule amount for code 99213 is $100. The participating provider's usual charge for this service is $125. Calulate the Medicare reimbursement amount

$80.00

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The first listed diagnosis reported on a CMS1500 form is the

Major reason the patient sought medical care

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The concept of linking diagnosis codes with the procedure /service codes is called

Mewdical necessity

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The patient is a 39 year old female on lithium who is unable to discontinue the medication and who doews not desire to become pregnat while on the medication> The patient therefore desires urgical sterliization> The patient was admitted to the ambulatory

v25.2;58671

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the jdiagnosis code reported in item 1 block 21 of hte CmS 1500 Form claim is hte

First listed Diagnosis

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Items 1-4 in Block 21 of the CMS-1500 claim link the listed diagnosis codes to the their appropriate procedure service codes reported in Bolock 23.these Itms are know as diagnosis ___numbers

Pointer

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The maximum number of CPT and or HCPCS modifiers that can be reported in block 23 of hte CMS-1500 claim is

four

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Block 25 of hte CMS-1500 claim requires entry of either the provider's social security number or the

EI N

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What is reported in Block 24 E of the CM S 1500

Diagnosis pointer number

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The patient is a 52 year old withe female who is deaf and ahas had bilateral carpal tunnel syndrome for and undetermined peroiod of time. The carpal tunnel syndrome is noted to be slightly greater in hte left thtn the right. The patient also has bilaterl

354.064721-RT, 26145-51 -RT 25115-51

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The "birtdauy rule" applies when dependent children living at home are covered by more than one health insurance policey . The primary policy is is determined bythe parent

who has a birthday that occures first in hte year

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The patient is covered by two health insurance policies, his own employer's group health plan and his spouss employer's group health plan> Which plan is primary for hte patient?

The patients won employer's group health plan is primary

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When a X appears in the YES box in block 10a of hte CMS-1500 claim, this indicates

The servicess provide were related to an on the job injury

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To prevent breach of patient confidentiality the patient mus either sign a n Authourization for Release of Medical Information: RoM statemen or

Sign Block 12 of the CMS-1500

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Which diagnosis is considered a chronic condidion tha twould always affect the patient care?

Diabetes mellitus

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If Laboratory procedures are performed inthe providers office how is the indicatedon the CMs 1500

By entering an X in the NO box of blosck 20 of hte CMS 1500

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If laboratiory procedures are performed int he profiders office how is this indicated ont he CMS 1500

by entering an X in NO box of Bock 20 of hte CMS 1500

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to jprevent breach of patient confidentiality, the patient must either sign and "Authorization for Release of Medical Information: ROM statement or

Sign Block 12 of hte CMS 1500 claim

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Which diagnosis is considered a chronic condition that would alweays affect the patient care?

Diabetes mellitus

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If laboratiory procedures are performed in the provider's office how is thes indicated on the CMS 1500 claim

By Entering a X in hte NO Box of Block 20 of hte DMS 1500

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Which of hte followin is considered a commercial health insurance company?

Atena

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Losses to a third party caused by the isured by an object owned byt he insured, or and pemises owned byt he isured are covered by ____ insurance

liability

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Which term describes the contractual right of a third party payer to recover healthcare expenses from a liable party

Subrogation

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The amount commonly chared for a specific medical service by providers within a particulare geographic region is known as the

reasonable and customary rate

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Which itme is considered a jplace of service for purposes of Block 24B on hte CMS 1500

Nursing facility

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Enter an X in hte yes box of Block 27 to indicate that hte provider agrees to

Accept assignment

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Disability insurance typically provides what type of compensation to the injured person?

Financial

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An participating provider is one who enters into a contract with a Blue Cross Blue Shield corporation and agrees to

Bill patients for only deductible and copay/coinsurance amounts

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Which offers discounted healthcare services to subscribers who use designated healthcare providers (who sign contracts) but which also provides coverage for services re

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Which of the following is considered a commercial health insurance company?

/Aetna

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Losses to athird party cause by the insured bya n object owned by a the insured, or on premises owned by the insured are covered by ____insurance

Liability

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Which term describes the contractual right of a third party payer to recover health care expenses form a liable party?

Subrogation

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The amoun commonly charged for a specific medical service by proveiders within a particulare georgraphiregion is know as the

usual customary and reasonable rate

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Which item is considered a place of srervice for puposes of Bolock 24B on hte CMS 1500

Nursing Facility

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Enter an X in hte yeas box of Block 27 to indidcate that hte provider agreess to

Accept assignment

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Disablility insurance typically provides what type of compensation tto the injured person

Financial

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A particpating provider is one who enters thinto a contract with a tBlue Cross Blue Shield corporation and agrees to

Bill patients for only deductible and co pay /coninsurance amounts

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Which offers discounted healthcare services to subricbers who use designated healthcare providers ( who sign contracts) but which also provides coverage for services rendered by healthcare providers who are not part of the networkd?

PreFerred provider organization

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Which concept applies when BCBS directly reimburses participating provieders for healthcare services rendered to subscribers?

Assingment of Benefits

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Business entities thta pay taxes on hte profits generated by teh corporation and distribute after tax profits to shareholders and officcers are ___organizations

For =Profit

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A special clause written into a contract that stipulated additonal coverage over and above the standard contract is a n

Rider

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Whcih Feature makes a BCBS plan different from other commercial plkans?

BCBSprovides billing manual and mewsletters to keep PARs up to date on insurance procedures

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ble to an individual who has wordked at least

10 years in Medicare covered employmen, is at least 65 years old, and is a citizen or permanet resident of hte US

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The general enrollement period for medicare art B coverage

Is heal from January 1 Through March 31 each hyear

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A medicare benefit period begins

With the first day of hospitalization and ends when the patient has been out of hte hospital for 60 consecutive days

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A medicar private contract is an agreement between the medicare beneficiary and a physician who has opted out of Medicare for tow years. Ths means that

The physician cannot bill for any serices or supplies provided to any Medicare beneficiary for at least two years

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Which of hte lfollosing is considered a commericial health insurance company

Aetna

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Losses to athird jparty cause dby the insured by an object owned byt he insured , or premises owned byt he insured are coverd byt ____ insurance

Liability

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Which term describes the contractural right of a third party payer to recover healthcare expe

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Individuals automatically enrolled in Medicare Part A are those who

Already receive social secureity, Railroad Retirement Board aor Disabbility benefits and are not yeat age 65

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Medicare Supplementary insurance is also Known as

Medigap

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The purpose of hte advance beneficiary notice is to alert the patient that

A service is unlikely to be reimbursed by Medicare and that hte patient must guraantee payment for services

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The deadline for liling Medicare claims is

December 31 of the year in which hte service was provided

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Certain individuals who have resources at or below twoic the standard allowed under the SSI program and income at or below 100 percent of hte FPL do not have to pay their monthly Medicare premiums, deductibles and coinsurance; thay are categorized

Qualified Medicare beneficiaries

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The Medicaid program that makes cash assistance available on a time-limted basis for children deprived of support because of a parent's death, incapacity absence or unemployment is hte

Temporary Assistance to Needy Families

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How frequently should a patients Medicaid elgibility be verified

With each isit to the provider

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States rarely require Medicaid recipients to pay a

Premium

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Medicaid will condidtionally subrogate claims

When there is liability insurance to cover a person's injuries

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Block 23 of hte CMS 1500 claim contains the Medicaid ___ number if applicable.

Preauthorization

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Which of hte flollowin practices is prohibited by law?

Balance billin of Medicaid paiiens

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Tricare is a healthcare program for

Active duty members of the military and their qualified family members

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Tricare Standard enrolleses are responsible for paying an annual __ as well as opayments

deductible

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A comprehensive healthcare program for which the Department of Veterands Affairs shares costs of comvered healthcare services and supplies with eligible beneficiareies is called

Champva

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What system is used to confirm Tricare eligibility for sponsors and their dependents

Defense Enrollemnt Eligibility Reorting System

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Blodk 31 of hte CMS 1500 claim submitted to Tricare must contain the

Name and credentials of hte provider

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The workers compensation First Report of Injury from is completed when the

Patient frist seeks treatment oror a work related illness or injury

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What is hte definition of atemporary partial disability

The employees wage earning capacity is partially lost but only on a temporary basis

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The tupe of workers compensation claim that is easiest to process is

Medical treatment

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The person resposible for completing the First Report of Injury is the

Treating jphysician

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A workers compensation progress report is filed when

There is any significant change in hte jworker's medical or disability

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An employee will lose the right to workers compensation coverage if the injury results solely form

drug or alcohol intoxication

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orkers compensation premium are paid by the

employer

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What information is entered in Block 11 of the Cms1500 claim form for a workers compensation case

The workers compansation jclaim number is entered in Block 11 of hte Cms1500

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Workers compensation laws potect the employer by

Limiting the award an injured employee can recover from an employer

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