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Reimbursement Final
| Question | Answer |
|---|---|
| The process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim is called: | coding |
| Which of the following is not a professional association for health insurance specialists? | American Medical Association |
| If preauthorization for treatment by specialists and post-treatment reports were not filed, the claim would be: | denied |
| 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 |
| Providers who send data in a standardized machine-readable format to an insurance company via disk, telephone modem, or cable are implementing: | electronic claim processing |
| What does CPT stand for? | Current Procedural Terminology |
| Preventive services: | may result in the early detection of health problems allow treatment options that are less dramatic and less expensive |
| Health insurance is able to: | individuals who participate in 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 |
| According to the U.S. Census Bureau data from 2005, what percentage of people in the U.S. are covered by government plans (e.g., Medicare, Medicaid, TRICARE): | 27% |
| 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 |
| This type of insurance provides coverage for catastrophic or prolonged illness and injures: | major medical insurance |
| The health care plan that reimburses providers for individual health care services provided is a: | fee-for-service plan |
| A method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patient prior to the administration of care is: | utilization management |
| What organization is owned by hospital(s) and physician groups that obtain managed care plan contracts? | Physician-hospital organization |
| A network of physicians and hospitals that have joined together to contract with insurance companies to provide health care to subscribers for a discounted fee: | preferred provider organization |
| Consumer-directed health plans provide incentives for controlling health care expenses and give individuals a(an) ________ to traditional health insurance and managed care coverage. | alternative |
| Federal legislation mandated that Managed Care Organizations (MCOs) participate in quality assurance programs and other activities including: | utilization and case managements requirements for second surgical opinions disclosure of any physician incentives |
| The development of a(an) ________ begins when the patient contacts a health care provider's office and schedules an appointment. | Insurance claim |
| The ________ is the person responsible for paying the charges. | Guarantor |
| Before scheduling an appointment with a specialist, a managed care patient must obtain a: | referral from the PCP or case manager copy of their medical records |
| Generate a separate ________ record and ________ record for each patient to maintain eac type of information. | financial, medical |
| ________ is the insurance plan responsible for paying health care insurance claims first. | Primary insurance |
| Regulated fraud associated with military contractors selling supplies and equipment to the Union Army. | False Claims Act |
| Participants maintain, at their own expense and at the same rate, health care plan coverage that would have been lost due to a triggering event (e.g., termination of employment). | Consolidation Omnibus Budget Reconcilation Act |
| In 1996, Congress passed the ________ because of concerns about fraud and abuse. | Health Insurance Portability and Accountability Act |
| ________ is the storage of documentation for an established period of time, usually mandated by federal and/or state law. | Record retention |
| 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 |
| An example of overpayment is: | payment to a physician on a nonassigned claim duplicate processing of charges/claims payment based on a charge that exceeds the reasonable fee |
| ________ codes are located in the Tabular List of Diseases and are assigned for patient encounters when a circumstance other than a disease or injury is present. | V codes |
| Removal of a cast applied by another physician, personal history of breast cancer, and exposure to tuberculosis are all examples of what types of codes? | V codes |
| The classification of Industrial Accidents According to Agency is found in what appendix of the ICD-9-CM? | Appendix D |
| It is always necessary that these codes be coded directly from the pathology report: | codes for neoplasms |
| CPT codes are used to report services and procedures performed on patients: | by providers in offices, clinics, and private homes by providers in institutional settings such as hospitals and nursing facilities when the provider is employed by the health care facility |
| Procedures and services submitted on a claim must be linked to the ________ that justifies the need for the service or procedure. | ICD-9-CM code |
| Of the following, which is/are sections of the CPT manual? | Medicine Pathology and Laboratory Radiology |
| A complete list of codes that include moderate (conscious) sedation is located in which appendix of the CPT manual? | Appendix G |
| Which modifier is assigned when the E/M service is "above and beyond" what is normally performed? | -22 |
| ________ is defined by Medicare as equipment that can withstand repeated use in the patient's home and not in the absence of illness or injury. | Durable medical equipment |
| The HCPCS level II coding system has which of the following characteristics? | ensures uniform reporting of medical products or services on claims forms uses code descriptors to identify similar products or services is not a reimbursement methodology for determining coverage or payment |
| ________ are used when the information provided by a HCPCS code descriptor has to be supplemented to identify specific circumstances that may apply to an item or service. | Modifiers |
| Which HCPCS level II modifier is applied to report anesthesia services performed personally by an anesthesiologist? | AA |
| Which HCPCS level II modifier would you use to report lower right eyelid? | E4 |
| How many levels of HCPCS codes are there? | 3 |
| Most state Medicaid programs use what type of system to report professional services, procedures, supplies, and equipment? | Healthcare Common Procedure Coding System |
| What type of codes are HCPCS level I codes? | Current Procedural Terminology codes |
| What does the acronym ROM stand for? | Risk of mortality |
| Which of the following is a federal health care program? | CHAMPVA Indian Health Services Medicaid |
| The ________ remiburses providers accordint to predetermined rates assigned to services, and is revides by CMS each year. | Medicare physician fee schedule |
| Medicare is always a secondary payer when a Medicare beneficiary also has coverage from which of the following groups: | workers' compensation veterans administrative benefits automobile medical or no-fault insurance |
| Which of the following is required information necessary to calculate the amount of Medicare secondary benefits payable on a given claim? | amount paid by the primary provider primary payer's allowable charge |
| How many diagnosis codes may be reported on each CMS-1500 claim? | Up to 4 |
| The ________ part of the note contains documentation of measurable or objective observations made during the physical examination and diagnostic testing. | Objective |
| Diagnostic test results are documented in how many locations? | Two |
| The development of an insurance claim begins: | when the patient contacts the health care provider's office for an appointment |
| Provider services for inpatient care are billed? | on a fee-for-service basis |
| In Block 21 of the CMS-1500 claim a maximum amount of ________ ICD-9-CM codes may be entered. | 4 |
| The ________ prohibits a payer from notifying the provider about payment or rejection of unassigned claims or payments sent directly to the patient/policyholder. | Federal Privacy Act of 1974 |
| The patient's birth date should appear on the CMS-1500 claim as: | MM DD YYYY |
| Block 24 of the CMS claim is limited to reporting how many services? | 6 |
| Supplemental health insurance plans usually cover: | deductibles co-payments coinsurance expenses |
| If the patient received inpatient services and has not been discharged at the time the claim is completed, the appropriate insertion in Block 18 would be: | none - leave blank |
| An exclusive provider organization (EPO) is simlar to: | an HMO |
| A PCP is a: | primary care provider personal care physician personal care provider |
| A special accidental injury rider covers: | 100% of nonsurgical care rendered within 24-72 hours |
| Teh BCBS PPO plan is: | a subscriber-driven program |
| The Federal Employee Health Benefits Program careds contain the phrase Government Wide Service Benefit Plan and employees have identification numbers that begin with the letter: | R |
| Blue Shield was created in 1938 and originally covered: | physician services |
| The largest single medical benefits program in the United States is | Medicare |
| Medicare Part A covers: | institutional providres for inpatient services |
| General Medicare eligibility requires an individual or their spouse to: | be a minimum of 65 years of age be a citizen or permanent resident of the United States have worked at least 10 years in Medicare-covered employment |
| A benefit period begins with the first day of hospitalization and ends when a patient has been out of the hospital for ________ consecutive days. | 60 |
| The benefit period was formerly known as: | spell of sickness spellof illness |
| Medicare reimburses provider services according to: | a physician fee schedule Resource-Based Relative Value Scale |
| RVUs consider resources used in providing a service, such as: | physician work physician expense malpractice expense |
| What is California's equivalent to the Medicaid program? | Medi-Cal |
| Medicaid is jointly funded by the ________ and ________ governments to assist states in providing adequate medical care to qualified individuals. | Federal/state |
| Which of the following would be covered under Medicaid? | pregnant women and resultant newborn children and teenagers, up to 18 or 21 depending on state aged (65 years of age or older), blind, or disable low income individuals |
| What does the acronym TANF stand for: | Temporary Assistance for Needy Families |
| TANF was previously known as? | Aid to Facilities with Dependent Children |
| Which of the following is not a mandatory service offered by states? | Nursing facility services for individuals under the age of 21 |
| Medicaid operates as a(an) ________ payment system. | vendor fee-for-service |
| What type(s) of services are exempt from copayments from Medicaid recipients? | emergency family planning |
| The portion of the Medicaid program paid by the federal government is known as the : | Federal Medical Assistance Percentage |
| Dual eligibles refers to: | individuals entitles to Medicare and Medicaid services |
| Any provider who accepts a Medicaid patient must accept the Medicaid-determined payment as: | payment in full |
| Providers receive reimbursement from Medicaid on what type of basis? | lump-sum several claims at once |
| Some braches of the military that are covered under TRICARE include: | Army Navy Air Force |
| MTF is the acronym for: | Military Treatment Facilities |
| A ________ is formal approval obtained from a health care finder before certain specialty procedures and inpatient care services are rendered. | Preauthorization |
| Individuals eligible for TRICARE Prime include: | active duty military personnel family members of active duty sponsors retirees and their family members who are under 65 years of age |
| How many health care options does TRICARE offer? | 3 |
| ________ and ________ laws require employers to maintain workers' compensation coverage for employees for work-related illnesses and injuries. | Federal/state |
| What was the previous name for Workers' Compensation? | Workman's Compensation |
| The Department of Labor manages programs designed to prevent work-related injuries and illnesses, which include: | Mine Safety and Health Administration Occupational Safety and Health Administration Jones Act |
| The Division of Federal Employees' Compensation Act processes: | medical expenses and compensation benefits to injured workers and survivors |
| The State Insurance Fund is a quasi-public agency that provides: | workers' compensation insurance coverage to private and public employers an agent in state workers' compensation cases involving state employees |
| Workers' compensation insurance provides ________ cash payments and reimburses health care costs for covered employees who develop a work-related illness or sustain an injury while on the job. | weekly |
| Self-insurance plans are required to: | purchase policies from commercial insurance companies for workers' compensation have sufficient capital to qualify |
| Who is responsible for determining the extent of disability of an employee? | Employee's health care provider |
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