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Mod H Unit 1


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
Created by: pdeal



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