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Mod H Unit 1
Review
| Question | Answer |
|---|---|
| When an unlisted procedure code is reported you must attach the | claim attachment |
| A preprinted form customized to the practice’s specialty, listing procedures and diagnoses common to the practice as well as codes and fees is the | encounter form |
| The primary objective in submitting claims is to submit | clean claim |
| The patient/insured section of the CMS-1500 includes blocks _____________ through ____________ | 1-13 |
| A common cause for insurance claims to be rejected is invalid patient | diagnostic code |
| Identify an important advantage of filing claims electronically reduce | reimbursement time |
| A medical record should document the healthcare professional's | findings |
| The document on which patients’ charges and payments are recorded is the_ | ledger card |
| The source for patient information, such as name of insurer, policy number, copayment, and/or name of primary care physician, can be found on | insurance identification card |
| An example of a correctly reported birth date in block 3 of the CMS-1500 is | 09 14 2008 |
| One of the health insurance professional’s most important responsibilities is maximizing | reimbursment |
| Submitting insurance claims directly to a third-party payer is called | direct data entry |
| The two main sections of the CMS-1500 are | pt/supplier |
| A claim that has no errors, omissions, and can be processed without delays is called a | clean claim |
| The bottom half of the CMS-1500 form is used for | physician/supplier info |
| The main reason for revising the CMS-1500 form is for HIPAA mandated | NPI |
| The 9-digit federal tax identification number is commonly referred to as the | EIN |
| Documents needed to complete a paper CMS-1500 include | pt info, insurance card, and health record |
| The front side of the CMS-1500 is printed in 33 block | OCR red ink |
| Medicare claims must be submitted electronically, unless the HHS Secretary grants a | waiver |
| Patient information is entered in what section of the form | top |
| Specific guidelines for OCR scan able claims include | no dollar signs or decimal points, upper case, 8 digit bday |
| `The most common format used for computer text files and on the Internet is | ASCII |
| OCR works best with original copies using | mono spaced font |
| Members of a PPO normally do not have to choose a | primary care provider (PCP) |
| A system designed to determine the medical necessity and appropriateness of a requested medical service or procedure is a | utilization review |
| A multispecialty practice in which health care services are provided within the building complex owned by the health maintenance organization (HMO) is referred to as a | staff model |
| A specific provider who oversees the entire care and treatment of a patient in an HMO is called a | primary care |
| The formal term for a written complaint submitted by an individual covered by a special plan or policy is called a | grievance |
| A document prepared by the carrier that gives details of how a claim was adjudicated is called a | explanation of benefits |
| To reduce unnecessary inpatient/outpatient services, managed care plans use | utilization review |
| A group of health care providers working under one umbrella to provide medical services at a discount to the individuals who participate in the plan is referred to as a | PPO |
| Today, the “Blue System” is the largest single processor of Medicare claims, which is called a | fiscal intermediary |
| Individuals who are members of a managed care plan are commonly referred to as | enrolless |
| The plan types within managed care plans include what 3 types of insurance | POS, HMO, PPO |
| A health care provider trained in a specific medical specialty is a | specialist |
| Many Americans obtain health insurance owing to their employment through what is commonly referred to as | group insurance |
| A private, nonprofit organization that accredits health care plans based on evaluation of the quality of care given to plan members is the | NCQA |
| With many MCOs, the enrollee typically pays a small fee upfront when visiting his or her PCP called a | copayment |
| A request by a health care provider for his or her patient to be evaluated or treated by a specialist is a | referral |
| When a patient is sent to another provider (often a specialist) with the intent of rendering an expert opinion on a specific health complaint, it is called a | consultation |
| When the employer—not an insurance company—is responsible for the cost of medical services, it is referred to as | self insurance |
| Policy premiums, yearly deductible, and coinsurance are the three out-of-pocket costs in | fee for service (FFS) |
| What organizations is responsible for creating the revised CMS-1500 | NUCC/NUBC |
| A type of HMO whereby services are provided by outpatient networks composed of individual health care providers who supply all necessary patient care is a | IPA |
| Many self-insured groups hire a specific type of organization to manage and pay claims is called | ERSA's/ASO's |
| The four basic types of health insurance fall into two broad categories, which are | indeminty/managed care |
| The private, not-for-profit organization dedicated to improving health care quality and frequently referred to as the managed care “watch dog” is | NCQA |
| Many FFS policies set a limit for what they will reimburse their members for any charges incurred, which is referred to as a life time | insurance cap |
| PAR providers contracting with Blue Cross Blue Shield must file claims within 365 days following the last date of service provided to the patient. This is referred to as | timely filing |
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