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Test 1-5 Reimburse

Includes Review for chapters 1-5

To remain up-to-date with the frequent changes of health insurance processing, health insurance specialists should: make certain they are on mailing lists to receive newsletters from third-party payers remain current on news released by the CMS Stay current with the DHHS updates
The process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim is called: coding
Another name for health insurance specialist is: Reimbursement specialist
What involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity of performing that procedure or service? Medical necessity
ICD-9-CM stands for: International Classification of Diseases-Ninth Revision, Clinical Modification
What does CPT stand for? Current Procedural Terminology
A successful health insurance specialist should have which of the following characteristics: Attention to details Strong sense of ethics Ability to work independently
Health insurance is available to: Individuals who participate in the individual (personal) health plans Participants of a prepaid health plan Individuals who participate in group (employer-sponsored) health plans
Reimbursement for income lost as a result of temporary or permanent illness or injury is: Disability insurance
What is the program mandated by federal and state governments that requires employers to cover medical expenses and loss of wages for workers who are injured on the job? Workers' compensation
The CMS-1500 claim form is used to report: Professional services Technical services
The ________ is the person responsible for paying the charges Guarantor
__________ is the insurance plan responsible for paying health care insurance claims first Primary insurance
When children are covered by the insurance policies of both parents, the ________ states that the parent whose birth month and day occurs earlier in the calendar year holds the primary policy Birthday rule
The patient ledger is also known as the: Patient account record
In 1996, Congress passed the ________ because of concerns about fraud and abuse. Health Insurance Portability and Accountability Act
The most common form of Medicare fraud is: Billing for services not provided Misrepresenting the diagnosis to justify payment Soliciting, offering, or receiving a kickback
Which of the following is not an example of abuse? Excessive charges for services, equipment, or supplies
Standards of laboratory testing CLIA
Forerunner of today's managed care plans Medicare
Contract that protects from loss Insurance
Weekly benefit amount divided into quarters Base period
Healthcare services to subscribers in a given geographical area for a fixed fee HMO
Promotes correct coding methodologies NCCI
Identification of disease and provision of care Medical care
Amount the patient is financially responsible for before an insurance policy provides payment Deductible
Specified amount paid for each physician visit Major Medical Insurance
Patient visit documentation Patient record
Title XIX of the SSA of 1965 Medicaid
Percentage of cost patient shares with the health plan Coinsurance
Protection from occupational hazards in the workplace OSHA
Insurance plan responsible for paying claims first Primary insurance
Clearinghouse that involves vendors, like banks, in the processing of claims Value-added network (VAN)
Hospital financial record source document Electronic flat file
Electronic format standard that uses a variable length file ANSI ASC X12
Primary policy determination for covered children Birthday rule
Physician does not contract with the insurance plan Non-PAR
Chronological summary of all transactions posted on a specific day Patient account record
Reported on claims to provide clarification about procedures and services performed Modifiers
Supporting documentation associated with a healthcare claim or patient encounter Claim attachment
Father's plan is always primary when child is covered by both parents Gender rule
Maximum amount the payer will allow for a procedure or service Allowed charges
Physician's financial record source document Encounter form
Payment Error and Prevention Program PEPP
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 MMA
Recovery Audit Contractor RAC
False Claims Act FCA
Tax Equity and Fiscal Responsibility Act of 1983 TEFRA
Balanced Budget Refinement Act of 1999 BBRA
Health Insurance Portability and Accountability Act of 1996 HIPAA
Omnibus Consolidated and Emergency Supplemental Appropriations Act of 1999 OCESAA
Consumer-direct Health Plan CDHP
Group Practice Without Walls GPWW
Point-of-Service Plan POS
Individual Practice Association IPA
Preferred Provider Organization PPO
Physician-Hospital Organization PHO
State Children's Health Insurance Program SCHIP
Exclusive Provider Organization EPO
The Medicare Catastrophic Coverage Act of 1988 mandated the reporting of ICD-9-CM diagnosis codes on what type of claims? All Medicare claims
An outpatient is a person treated in which of the following settings: Hospital observation unit Ambulatory surgery center Physician's office
Patients signs Block 13 of the CMS-1500 claim to instruct the payer to directly reimburse the provider; this is an Assignment of benefits
The concept that every procedure or service reported to a third-party payer must be linked to a condition that justifies that procedure or service is called medical necessity
Which codes supplement procedures, services, and supplies not classified in CPT? HCPCS level II
Which is a typical responsibility of a health insurance specialist? Correcting claims processing errors
Which organization offers a payer certification exam? AAPC
The mutual exchange of information between providers and payers is called electronic data interchange
Conduct and qualities that characterize a professional person are called professionalism
The abbreviation for the Health Common Procedure Coding System HCPCS
The document submitted by a provider to a third-party for the purpose of requesting reimbursement for services provided is a claim
The process of classifying diagnoses, procedures, and services is called coding
The process of taking and passing credentialing exams (e.g., CPC) is called professional certification
Which coding system is used for reporting procedures and services in physician offices? CPT
Diagnoses are coded according to ICD-9-CM
Health insurance specialists play an important role in what process involving denied or underpaid claims? Appeal
Electronic data interchange is achieved by using a standardized, machine-readable format
Rules that govern the conduct of members of a profession are called Ethics
The notice received by a provider from a payer that contains payment information for a claim is the remittance advice
A coding consultant who is paid by a practice to assist the coding and billing staff would most likely be classified as an independent contractor
Which is another name for professional liability insurance? Errors and omissions insurance
Physician offices should bond employees who have which responsibility? Financial
Which term is another word for stealing money? Embezzling
A customer was severely injured in a grocery store when a pallet of soda cans toppled onto him. Which insurance would be billed for the customer's medical care? Liability
Which type of insurance provides financial and medical benefits for an injured employee? Workers' compensation
Health information management professionals can achieve coding certification by successfully passing an exam offered by which professional association? AHIMA
The study of the body and its structures is anatomy
The study of disease processes and abnormalities of the body is pathophysiology
A claim was submitted for a left shoulder x-ray 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
A patient was diagnosed with asthma. Which coding system is used to report this condition on the claim? ICD-9-CM
The type of health care that helps individuals avoid health and injury problems is preventive
In 1916, this law replaced the 1908 workers' compensation legislation, and civilian employees of the federal government were provided medical care, survivors' benefits, and compensation for lost wages. Federal Employees' Compensation Act
During World War II, the government restricted the wages employers could offer employees; thus, employers began offering which of the following to their employees? Benefits
When three or more doctors deliver health care and make joint use of equipment, supplies, and personnel, this is called a group practice
Which coding system is used to report procedures and services on physician office insurance claims? CPT
Which is a government-sponsored health program that provides benefits to low-income patients? Medicaid
The specified amount of annual out-of-pocket expenses for covered health care services that the insured must pay annually for health care is called the deductible
The standard claim developed by CMS and used to report procedures and services delivered by physicians is called the CMS-1500
What coding system was originally developed by the World Health Organization in 1948? ICD
The act passed in 1997 that resulted in the development of coding compliance programs by the federal government is the BBA
The act passed in 1996 that has had a great impact on confidentiality, electronic information transmission, and standardization is the HIPAA
The Veterans Healthcare Expansion Act of 1973 authorized the VA to establish what to provide health care benefits for dependents of veterans rates as 100% permanently and totally disabled as a result of service-connected conditions, veterans who died CHAMPVA
The ambulatory payment classification prospective payment system is used to reimburse claims for what service? Outpatient
The percentage of costs a patient shares with the health plan is the coinsurance
The Health Maintenance Organization Assistance Act of what year authorized federal grants and loans to private organizations that wished to develop HMOs, which are responsible for providing health care services to subscribers in a given geographic area 1973
The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) includes a payment classification system that reflects differences in patient resource use and costs, replacing which payment system with a per diem IPF PPS? Cost-based
The Standard Unique Health Identifier for Health Care Providers or National Provider Identifier (NPI), was implemented in 2005
What is the purpose of third-pary administrators (TPAs)? Administer health care plans and process claims
The federal legislation passed in 1981 that expanded the Medicare and Medicaid programs was OBRA
Which three components constitute the RBRVS payment system? Physician work, practice expense, and malpractice insurance expense
In which year was the first recognized commercial insurance company policy developed in the United States? 1860
An official from Baylor University in Dallas developed what is recognized now as the first example of which policy? Blue Cross
Insurance that is available through employers, labor unions, consumer health cooperatives, and other organizations is group health insurance
The type of insurance that provides coverage for catastrophic or prolonged illnesses and injuries is major medical
A provider's list of predetermined payments for health care services to patients is known as the fee schedule
Which term describes the process of developing patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner? Case management
The National Committee on Quality Assurance is a nonprofit organization that measures and evaluates the quality of a managed care plan's performance
Employees and dependents who join a managed care plan are called subscribers
Mandates are laws
The review for appropriateness and necessity of care provided to patients, prior to the administration of care or retrospectively, is called utilization management
Which type of HMO offers subscribers health care services by physicians who remain in their individual office settings? Independent practice association
Which act or amendment established an employee's right to continue health care coverage beyond a scheduled benefit termination date? COBRA of 1985
The 1988 Amendment to the HMO Act of 1973 added which provision? Federally qualified HMOs could permit members to occasionally use non-HMO providers and be partially reimbursed
A risk contract is defined as an arrangement among health care providers to make available capitated health care services to Medicare beneficiaries
If an HMO has met the federal standards established in the HMO Act of 1973, the HMO can be federally qualified
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 higher out-of-pocket costs
Illegal wording in a managed care contract that prohibits a provider from discussing all possible treatment options with a patient is what kind of a clause? Gag
Which type of managed care plan provides benefits to subscribers if they receive services only from network providers? Exclusive provider organization
A medical group that has been specially formed to service a particular HMO is part of what type of HMO? Closed panel
The newly emerging health plan that focuses on asking employees to be more responsible for health care decisions and cost sharing is what kind of health plan? Consumer-directed
When a provider receives a fixed amount to provide only the care that an individual needs from that provider, this is known as what kind of payment? Subcapitation
When a number of people are grouped for insurance purposes, this is known as a risk pool
A triple option plan can also be known as a cafeteria plan or a flexible spending plan
Which combines health care delivery with financing of services provided? Managed care
Which 2003 legislation allows tax deduction for amounts contributed to a health savings account? Medicare Modernization Act (MMA)
Managed care plans can contract with an outside vendor to establish and maintain a utilization management program. The plan can contract with a TPA or with a utilization review organization (URO)
The voluntary process that a health care facility or organization undergoes to demonstrate it has met requirements beyond those required by law is called accreditation
The patient account record that can be found in automated or manual format is also called the patient ledger
The specified percentage of charges the patient must pay to the provider for each service received or for each visit is the coinsurance
The financial record source document used to record services rendered in a physician's office is the encounter form
When the provider is required to receive as payment in full whatever amount the insurance reimburses for services, the provider is agreeing to accept assignment
Care rendered to a patient that was not properly approved (e.g., preapproved) by the insurance company is known as unauthorized services
The maximum amount the payer will allow for each procedure or service, according to the patient's policy, is the allowed charge
Approximately how many insurance claims are filed each year? More than 6 billion
Processing a claim begins at the Provider's office
Data transmitted electronically or manually to payers or clearinghouses is called claims submission
According to the national standards mandated by HIPAA for the electronic exchange of administrative and financial care transactions, which would be a covered entity? Managed care organization
Which organization facilitates the development of standards for health informatics and other industries, such as the international exchange of goods and services? ANSI
If a claim is found to contain all data elements needed for processing, it is known as what kind of claim? Clean
A procedure reported on a claim that is not included on the master benefit list will result in what? Denial
The remittance advice is called what by the Medicare program? Provider Remittance Notice (PRN)
The person responsible for paying the charges for services rendered by the provider is the Guarantor
Which document is used to generate the patient's financial and medical record? Patient registration form
The rule stating that the policyholder whose birth month and day occur earlier in the calendar year holds the primary policy for dependent children is what rule? Birthday
To save the expense of mailing invoices to patients, the office may ask the patient to pay the patient's portion of the bill before treatment or before the patient leaves the office
How long must providers retain copies of government insurance claims? 6 years
What type of claim is generated for providers who do not accept assignment? Unassigned
The process of submitting multiple CPT codes when one code should be submitted is unbundling
The insurance industry is regulated by whom? Individual states
The processing of a claim consists of how many stages? Four
Which allows for the direct submission of claims to payers using internet technology that emulates a system connection? Extranet
When a provider performs a procedure for which there is no CPT or HCPCS level II code available, what must be provided to the payer? Supporting documentation
Federal and state statues are passed by legislative bodies
Which term describes guidelines written by administrative agencies, such as CMS, that are based on laws passed by legislative bodies? Regulation
Case law is based on court decisions that establish precedent and is also called what? Common law
Which is the legal newspaper published daily by the National Archives and Records Administration (NARA) of the federal government? Federal Register
When a patient signs a release of medical information at a physician's office, that release is generally considered to be valid for 1 year from the date entered on the form
Breach of confidentiality can result from discussing patient health care information with unauthorized sources
Which term describes an individual's right to keep health care information from being disclosed to others? Privacy
Practices that submit hard-copy insurance claims obtain that patient's signature in Block 12, which is what block on the CMS-1500 claim? Release of medical information
The safekeeping of patient information by controlling access to hard-copy and computerized records is a form of security management
Undated signed forms are assumed to be valid until revoked by the patient or guardian
Information that is converted to a secure language format for electronic transmission is what kind of data? Encrypted
Which federal legislation was enacted in 1995 to restrict the referral of patients to organizations in which providers have a financial interest? Stark II laws
Testimony under oath taken outside the court (e.g., at the provider's office) is a deposition
An organization that contracts with CMS to process fee-for-service health care claims and perform program integrity tasks for Medicare Parts A and B is called a Medicare administrative contractor
In which year was the False Claims Act originally passed? 1863
Which act of legislation requires Medicare administrative contractors to attempt the collection of overpayments made under the Medicare or Medicaid programs? Federal Claims Collection Act
Excessive charges for services, equipment, or supplies is an example of abuse
The recognized difference between fraud and abuse is the intent
When a Medicare provider commits fraud, which entity conducts the investigation? Office of the Inspector General
A provider or beneficiary can receive a waiver of recovery of overpayment in which situation? The beneficiary was without fault with respect to the overpayment and recovery would cause financial hardship.
As party of the administrative simplification provision of HIPAA, which of the following unique identifiers is assigned to third-party payers? National Health PlanID (PlanID)
The HIPAA privacy rule states that "an individual has the right to inspect and obtain a copy of what information in a designated record set", except for psychotherapy notes, information compiled in anticipation of use in a civil, criminal, or administrati Protected health
The threat of excessive awards in medical liability cases has increased providers' liability insurance premiums, resulting in what? Increased health care costs
What is the best way to verify the identity of a caller requesting medical information? Use the call-back method
The purpose of the Correct Coding initiative is to reduce Medicare program expenditures
What organization is responsible for the health of a group of enrollees and can be a health plan, hospital, physician group or health system? Managed Care Organization
A fee schedule is a cost-based fee-for-service reimbursement methodology
TRICARE includes three plan options. Which of the following is not one of those options? TRICARE select
The check-in procedure for a patient who is ________ to the provider's office is more extensive than for a ________ patient. new; returning
This type of insurance provides coverage for catastrophic or prolonged illness and injuries: major medical insurance
This is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees' health status, age, sex, and occupation. Risk pool
Providers who send data in a standardized machine-readable format to an insurance company via disk, telephone modem, or cable are implementing: electronic claims processing
Medical necessity is the measure of whether a health care procedure or service is appropriate for: diagnosis and/or treatment of condition
The health care plan that reimburses providers for individual health care services provided is a: fee-for-service plan
Provider's notification regarding payment of claim Remittance advice
Liability insurance for providers Medical malpractice insurance
Prior approval Preauthorization
Diagnostic codes ICD-9-CM
Certified Professional Coder AAPC
Patient not responsible for paying what the plan denies Hold harmless clause
Reporting diagnoses, procedures, and services Coding
Principles of right or good conduct Ethics
HCPCS level I codes CPT
Physician Health care provider
Results of processing a claim sent to patient EOB
Exchange of data between provider and insurance company Electronic Data Interchange
Errors and omissions insurance Professional liability insurance
Physician's legal responsibility for actions of employees Respondeat superior
National codes HCPCS level II codes
Which act mandates regulations that govern privacy, security, and electronic transactions standards for health care information? Health Insurance Portability and Accountability Act of 1996
The ________ mandates the retention of patient records and health insurance claims for a minimum of 6 years, unless state law specifies a longer period HIPAA
If preauthorization for treatment by specialists and post-treatment reports were not filed, the claim would be: denied
The Occupational Safety and Health Administration Act of 1970 was designed to: protect all employees against injuries in the workplace
Liability insurance claims are made to: cover the cost of medical care for traumatic injuries or lost wages
Accurate coding of diagnoses, procedures, and services rendered to the patient allows a medical practice to: Facilitate analysis of the practice's patient base for improvement and efficiency Communicate diagnostic and treatment data to insurance plans for maximum recovery of benefits
________ is the storage of documentation for an established period of time, usually mandated by federal and/or state law. Record retention
An exclusive provider organization (EPO) is similar to: HMO
Recovery Audit Contractor RAC
Health Insurance Portability and Accountability Act of 1996 HIPAA
Omnibus Consolidated and Emergency Supplemental Appropriations Act of 1999 OCESAA
Payment Error and Prevention Program PEPP
Balanced Budget Refinement Act of 1999 BBRA
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 MMA
False Claims Act FCA
Tax Equity and Fiscal Responsibility Act of 1983` TEFRA
The CMS-1500 claim form requires responses to standard questions pertaining to whether the patient's condition is related to: An auto accident Secondary Insurance Employement
Which of the following is not an example of a managed care plan? Consumer-directed health plan
According to the U.S. Census Bureau data from 2005, what percentage of people in the United States are covered by government plans (e.g., Medicare, Medicaid, TRICARE) 27%
The CPT manual is published by the: American Medical Association
According to the Health Insurance Association of America, what is the largest area of health care fraud? Misrepresenting diagnoses
If the insurance plan has a hold harmless clause it means: the patient is not responsible for paying what the insurance plan denies
Regulated fraud associated with military contractors selling supplies and equipment to the Union Army. False Claims Act
What organization is owned by hospital(s) and physician groups that obtain managed care plan contracts? Physician-hospital organization
The first Blue Shield plan was founded in: California
Title XVIII of the SSA of 1965 Medicare
Standards of laboratory testing CLIA
Health care services to subscribers in a given geographical area for a fixed fee HMO
Coverage for prolonged illnesses and injuries Major Medical Insurance
Promotes correct coding methodologies NCCI
Specified amount paid for each physician visit Copay
Contract that protects from loss Insurance
Forerunner of today's managed care plans Prepaid health plans
Protection from occupational hazards in the workplace OSHA
Weekly benefit amount divided into quarters Base period
Title XIX of the SSA of 1965 Medicaid
Percentage of cost patient shares with the health plan Coinsurance
Amount the patient is financially responsible for before an insurance policy provides payment Deductible
Contractual right of a third-party payer to recover health care expenses from a liability party Subrogation
Identification of disease and provision of care Medical care
A plan offered either by a single insurance plan or as a joint venture by two or more insurance carriers, and which provides subscribers or employees with a choice of HMO, PPO, or traditional health plan is a: A triple option plan Cafeteria plan Flexible benefit plan
Who requires physician offices to submit ICD-9-CM codes on CMS-1500 claim forms? Medicare
Disability insurance provides the disabled person with financial assistance, but does not generally pay for: Unemployment insurance benefits Medical services
A point of service plan (POS): allows subscribers to choose between a network provider or out-of-network provider
Preventive services: May result in the early detection of health problems Allow treatment options that are less dramatic and less expensive
Created by: adale3171