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Reimbursement Final

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
Created by: adale3171