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chapter 16 Book Ques
Chapter 16 Health Insurance Systems/ Claim Submission
| Question | Answer |
|---|---|
| The "Insured" is also known as | Member,policyholder,subscriber, or recipient |
| In an insurance contract, the waiting period is | A time frame after the beginning date of a policy before benefits for illness or injury become payable, also called the elimination period |
| Unit values for each procedure code are used in the followed payment method | Relative Value Scale/ Studies (RVS) |
| Medical necessity is insured when the insurance when the insurance carrier mandates | Is preauthorization |
| The oldest of all prepaid health plans | HMOs ( Health Maintenance Organization) |
| Medicaid is sponsored by | Federal, state, & local gov't |
| When working in the physician's office, you will be billing | Part B |
| The system Medicare uses to calculate fees | Resource- Based Relative Value System |
| In the TRICARE program, an enrollment fee is sometimes charged for | TRICARE Prime |
| State disability is available in Puerto Rico & the state of | California, Hawaii, NJ, NY, & Rhode Island |
| In workers' compensation case, who does the medical assistant communicate with | Adjuster |
| The CMS-1500 claim form has an assignment of benefits for government program in | Field 12 |
| A standard unique health identifier for the health care provider is called a/ an | (NPI) National Provider Identifier |
| The reason that the CMS 1500 claim form is printed in red ink is | To comply w/ OCR (Optical Character Recognition) machines` |
| Some advantages of electronic transmission of claims are | Have fewer errors & omissions, quicker turnaround time, increase cash flow, & built-in code edit checks |
| A claim scrubber is | Built-in edits in electronic software that prompt the biller to change or enter information on claims |
| An Advance Beneficiary Notice | Must be completed when it is suspected that Medicare may not deem a service or supply medical necessary |
| A suspended claim is a | Claim held by the insurance company as pending because of an error or the need for additional information |
| Liability under the False Claims Act Can lead to civil monetary penalties for every fraudulent claim filed, ranging from | $5,500 to 10,000 |
Created by:
jcpickens