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chapter 09 insurance
| Question | Answer |
|---|---|
| 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