Question 1

Patients can be billed for___________ but not _________.

Accepted Answer

non-covered procedures
unauthorized services

Question 2

Guarantor

Accepted Answer

Person responsible for paying the charges

Question 3

when does the development of an insurance claim begin?

Accepted Answer

When the providers office completes and submits the CMS-1500 form

Question 4

the check in procedure for a patient who is new to the providers office is __________ than a returning patient.

Accepted Answer

More extensive

Question 5

Claims attachment

Accepted Answer

supporting documentation or information that is associated with a healthcare claim or patient encounter

Question 6

it is necessary to submit a claims attachment when using an

Accepted Answer

unlisted CPT code

Question 7

accept assignment

Accepted Answer

the provider agrees to accept what insurance allows or approves as payment in full for the claim

Question 8

CMS-1500 form requires responses to standard questions pertaining to:

Accepted Answer

auto accident: secondary insurance and employment (among other things)

Question 9

clean claim

Accepted Answer

contains all required data elements needed to process and pay the claim

Question 10

what do you need to know to process a claim

Accepted Answer

Name and phone number of the third party payer and the name of the policy holder (among other things)

Question 11

SOF

Accepted Answer

signature on file can be submitted as patient signature as long as the signature is on file in the office.

Question 12

CMS-1500 form is used to .............

Accepted Answer

report professional and technical services

Question 13

If a payer marks a claim with "pending" status,

Accepted Answer

the provider can  respond by correcting errors and omissions on the claim and resubmit for reconsideration

Question 14

appeal

Accepted Answer

a letter signed by the provider explaining why a claim should be reconsidered for payment

Question 15

PAR: Participating Provider

Accepted Answer

contracts with a health insurance plan and accepts whatever the plan pays for procedures and services performed.

The PAR is not allowed to bill the patients for the difference (called balance billing).

Question 16

Encounter Form

Accepted Answer

the financial record source document used by healthcare providers to record treated diagnoses and services rendered to the patient during the encounter

Question 17

Clearing houses process claims that are filed in a ____________ and _________.

Accepted Answer

"flat" format

converted to a "standard" format

Question 18

The birthday rule

Accepted Answer

a policy determination for covered children

Question 19

what happens when children are covered by the insurance policy of both parents?

Accepted Answer

The birthday rule says the parents whose birthday month and day come first int he calender year holds the primary policy.

Question 20

Day sheet

Accepted Answer

chronological summary of all transactions posted on a specific day

Question 21

Before scheduling an appointment with a specialist,

Accepted Answer

a managed care patient must obtain a referral form their PCP or Case Manager

Question 22

Gender Rule

Accepted Answer

states the father's plan is always primary when the child is covered by both parents

Question 23

Primary insurance is the insurance plan...

Accepted Answer

responsible for paying health care insurance claims first

Question 24

what are SOAP notes used for?

Accepted Answer

they are used in providers offices to document patients visits

Question 25

What does the health information specialist have the patient do when arriving at the doctor's office?

Accepted Answer

Have the patient complete a patient registration form

Question 26

Patient Account Record

Accepted Answer

computerized record of all financial transactions between patients and the pratice

Question 27

Generate a separate __________ and __________ for each patient to maintain each type of information.

Accepted Answer

financial record and medical record

Question 28

claim attachment

Accepted Answer

supporting documentation associated with a healthcare claim for patient encounter

Question 29

The patient account record is also called the

Accepted Answer

patient ledger

Question 30

electronic flat file

Accepted Answer

clearinghouse claims processing format

Question 31

What two things are used by healthcare providers to record services and diagnoses rendered during the visit?

Accepted Answer

superbill and encounter form

Question 32

chargemaster

Accepted Answer

hospital financial record source document

Question 33

NonPAR is a physician who is.....

Accepted Answer

NOT contracted with an insurance company

Question 34

Modifier

Accepted Answer

reported on claims to provide clarification about procedures and services performed

Question 35

VAN

Accepted Answer

Value-added Network; clearinghouse that involves vendors like banks, in the processing of claims

Question 36

examples of covered entities

Accepted Answer

Private sector health plans
Managed Care Organizations
ERISA-covered benefit plans
Government health plans
Healthcare clearinghouses 
Providers that submit or receive claims electronically

Question 37

_________ insurance pays first and ________________pays after that.

Accepted Answer

Primary
Secondary

Chapter 4

study guide

Question	Answer
Patients can be billed for___________ but not _________.	non-covered procedures unauthorized services
Guarantor	Person responsible for paying the charges
when does the development of an insurance claim begin?	When the providers office completes and submits the CMS-1500 form
the check in procedure for a patient who is new to the providers office is __________ than a returning patient.	More extensive
Claims attachment	supporting documentation or information that is associated with a healthcare claim or patient encounter
it is necessary to submit a claims attachment when using an	unlisted CPT code
accept assignment	the provider agrees to accept what insurance allows or approves as payment in full for the claim
CMS-1500 form requires responses to standard questions pertaining to:	auto accident: secondary insurance and employment (among other things)
clean claim	contains all required data elements needed to process and pay the claim
what do you need to know to process a claim	Name and phone number of the third party payer and the name of the policy holder (among other things)
SOF	signature on file can be submitted as patient signature as long as the signature is on file in the office.
CMS-1500 form is used to .............	report professional and technical services
If a payer marks a claim with "pending" status,	the provider can respond by correcting errors and omissions on the claim and resubmit for reconsideration
appeal	a letter signed by the provider explaining why a claim should be reconsidered for payment
PAR: Participating Provider	contracts with a health insurance plan and accepts whatever the plan pays for procedures and services performed. The PAR is not allowed to bill the patients for the difference (called balance billing).
Encounter Form	the financial record source document used by healthcare providers to record treated diagnoses and services rendered to the patient during the encounter
Clearing houses process claims that are filed in a ____________ and _________.	"flat" format converted to a "standard" format
The birthday rule	a policy determination for covered children
what happens when children are covered by the insurance policy of both parents?	The birthday rule says the parents whose birthday month and day come first int he calender year holds the primary policy.
Day sheet	chronological summary of all transactions posted on a specific day
Before scheduling an appointment with a specialist,	a managed care patient must obtain a referral form their PCP or Case Manager
Gender Rule	states the father's plan is always primary when the child is covered by both parents
Primary insurance is the insurance plan...	responsible for paying health care insurance claims first
what are SOAP notes used for?	they are used in providers offices to document patients visits
What does the health information specialist have the patient do when arriving at the doctor's office?	Have the patient complete a patient registration form
Patient Account Record	computerized record of all financial transactions between patients and the pratice
Generate a separate __________ and __________ for each patient to maintain each type of information.	financial record and medical record
claim attachment	supporting documentation associated with a healthcare claim for patient encounter
The patient account record is also called the	patient ledger
electronic flat file	clearinghouse claims processing format
What two things are used by healthcare providers to record services and diagnoses rendered during the visit?	superbill and encounter form
chargemaster	hospital financial record source document
NonPAR is a physician who is.....	NOT contracted with an insurance company
Modifier	reported on claims to provide clarification about procedures and services performed
VAN	Value-added Network; clearinghouse that involves vendors like banks, in the processing of claims
examples of covered entities	Private sector health plans Managed Care Organizations ERISA-covered benefit plans Government health plans Healthcare clearinghouses Providers that submit or receive claims electronically
_________ insurance pays first and ________________pays after that.	Primary Secondary

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