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Stack #2176425
meda 160 chap 7 & 8 reviewer
| Question | Answer |
|---|---|
| The health insurance claim form (CMS-1500) is known as the | Universal Claim Form. |
| An insurance claim form that contains no staples or highlighted areas and on which the bar code area has not been deformed is called | A physically clean claim. |
| An insurance claim submitted with errors is referred to as | A dirty claim |
| What is the protocol to follow on receiving a request for an attending physician’s statement from an insurance company on a patient who has applied for health insurance? | (D) Request a fee from the insurance company before sending the attending physician statement |
| If you receive a request, accompanied with the correct authorization, asking to abstract medical information from a patient’s medical record | (B) send only the information requested |
| Office visits may be grouped on the insurance claim form if each visit | Is consecutive, uses the same procedure code, and results in the same fee. |
| OCR is the acronym for | Optical Character Recognition |
| OCR guidelines for the CMS-1500 claim form state | It should not be photocopied because it cannot be scanned. |
| To conform to CMS-1500 OCR guidelines | Do not fold insurance claim forms when mailing, do not use symbols with data on insurance claim forms, do not strike over errors when making a correction on an insurance claim form |
| How should blocks on an OCR CMS-1500 claim form be treated that do not need any information? | Leave the block blank |
| The CMS-1500 claim form is divided into which of the following major sections? | patient and physician information |
| The Health Insurance Claim Form, also known as the universal claim form, is often called or referred to as | CMS 1500 |
| A claim that is submitted to the insurance carrier via internet connection is referred to as | Electronic claim |
| When the patient is insured by two companies, the coverage is sometimes referred to as | dual coverage |
| A husband and wife both have insurance through their employers, and each has added the spouse to his or her insurance plan for coverage. If the wife is seen for treatment, then her plan is considered | Primary |
| An insurance claim that is submitted on paper, including optically scanned claims | paper claim |
| A Medicare claim that is missing required information | incomplete claim |
| An insurance claim held in suspense due to review or other reason | pending claim |
| An insurance claim that requires investigation and needs further clarification | Rejected claim process |
| An insurance claim that is submitted within the program or policy time limit and correctly completed. | clean claim |
| An insurance claim that is submitted via a dial-up modem or direct data entry. | electronic claim |
| An insurance claim that is submitted with errors. | dirty claim |
| A Medicare claim that contains complete, necessary information but is illogical or incorrect. | invalid claim |
| Missing place of service code. | verify that the place of service is correct for the submitted procedure code (s) and fill in correct service code. |
| The insurance claim was submitted to the secondary instead of the primary insurer. | I. Obtain data from patient during the first office visit on which company is the primary insurer |
| Patient’s name and insured’s name are entered as the same when the patient is a dependent. | check for Sr., Jr., correct birthdate, and verify the insured. |
| The patient’s insurance number is incorrect. | A. Proofread numbers carefully from source documents |
| Incorrect modifier. | G.Verify and submit valid modifiers with the correct procedure codes for which they are valid |
| Operative report is missing from the insurance claim. | J. Submit all attachments with the patient's name and insurance identification number |
| Procedure code is invalid. | refer to the current procedure codebooks and verify the coding system used by the insurance company. |
| Diagnostic code is missing. | C.Refer to an updated diagnostic codebook and review the patient record |
| Total amounts do not equal itemized amounts charged. | H. Total of all charges on each claim, recheck the math, and verify amounts with patient account |
| Duplicate dates of service listed. | D. Verify with the patient's medical record that all dates of service are listed and accurate |
| What is the patient’s diagnosis? | |
| What is the type of history and physical examination recorded for this patient? | |
| Where was the professional service performed? | |
| Who is the referring physician? | |
| Who is the policyholder of the insurance contract? | |
| The exchange of data in a standardized format through computer connections is known as electronic data interchange. | TRUE |
| Encrypted data often look like gibberish to unauthorized users. | TRUE |
| Even if a physician’s office does not bill Medicare and does not submit transactions electronically, directly, or through a third party, the practice is still subject to HIPAA transaction rules. | FALSE |
| When submitting a claim to Medicare, the name of the insured is required, not situational. | FALSE |
| A Medicare claim must include standard code sets, such as CPT and ICD-9-CM codes. | TRUE |
| Confidential data should be stored only in the computer’s hard drive. | FALSE |
| An installed firewall and antivirus software help maintain computer security. | TRUE |
| Practice management systems can be “rented” from practice management systems over the Internet. | TRUE |
| For insurance claims to be submitted electronically, a signed agreement by the physician with the carriers involved is necessary. | TRUE |
| Clearinghouses always charge a flat fee for claim processing. | TRUE |
| A group of insurance claims sent at the same time from one facility is known as a | BATCH |
| A clearinghouse is a/an | entity that receives transmission of insurance claims separate the claims and sends one electronically to the correct insurance payer |
| Insurance claims transmitted electronically are usually paid in | two weeks or less |
| The most important function of a practice management system is | acccounts receivable |
| The employer’s identification number is assigned by | IRS |
| A clearinghouse | transmits claims to the insurance payer, performs software edits, separates claim by carrier - (all the above) |
| Insurance claims form data are gathered | before the service is rendered, during the time the sevice is rendered, after the sevice is rendered - (all the above) |
| Back-up copies of office records should be stored | aways from the office |
| When a medical practice has its own computer and transmits claims electronically directly to the insurance carrier, this system is known as | carrier direct |
| A computer printout that is used to look for errors before an insurance claim is transmitted electronically is called | insurance billing worksheet |
| Back-and-forth communication between user and computer that occurs during online real time is called | interactive transaction |
| Assigning a code to represent data is known as ____________________. | Encryption |
| A combination of letters, numbers, or symbols that each individual is assigned to access the computer system is called a/an ____________________. | Password |
| When keying data, it is wise to ____________________ frequently to save information. | backup |
| An online transaction concerning the status of an insurance claim is called a/an ______________________________. | electronic remittance advice |
| Employees who have access to patients’ medical records must have a high degree of ____________________ and ___________________. | responsibility and accountability |
| A status report of claims is usually received ____________________. | electronically |
| For assignment of benefits, each patient’s ____________________ must be obtained. | signature |
| A screen prompt is a ____________________. | question field |
| An internal audit that reviews who has access to PHI is a/an ___________________ safeguard or security measure. | administrative safeguard or security measure |
| An automatic logoff that prevents unauthorized users from accessing a computer is a/an ___________________ safeguard. | technical safeguard |
| How the physician’s office handles the retention, removal, and disposal of paper records is a/an ____________________ safeguard. | physical safeguard |
| Post payments in practice management system. | daily or weekly |
| Note any problematic claims and resolve outstanding files. | weekly |
| Batch, scrub, edit, and transmit claims. | daily or weekly |
| Review all claim rejection reports. | end of month |
| Audit claims batched and transmitted with confirmation reports. | daily |
| Make follow-up calls to resolve reasons for rejections. | weekly |
| Review clearinghouse/payer transmission reports. | daily |
| Correct rejections and resubmit claims. | daily |
| Update practice management system with payer information. | end of month |
| Research unpaid claims. | weekly |
| Name three advantages of using a clearinghouse to bill insurance companies. | 1. reduction in time of claims preparation 2. cost-effective method through loss prevention 3, fewer claim rejections |
| List three additional names for an encounter form. | charge slip, multipurpose billing form and a patients service slip |
| What are the three kinds of information system safeguards security measures? | administrative, physical and technical |
| List the three ways in which clearinghouses are paid. | 1. a flat fee per claim 2. recoup the expense from the payer 3. a vendor agreement between business associate agreement or trading partner agreement |
| Medicaid, Medicare, and TRICARE use which system to eliminate the need for a clearinghouse? | they use a carrier-direct system |
| What does an electronic remittance advice (RA) do? | it is the status of a claim, tells you what has been paid or not |
| What is an encoder? | it is add-on software to practice management systems that reduce time researching a claim before batching |
| What are medical code sets? | it stream-lines the old system into a more efficient and cost effective system |
| Why was the HIPAA Transaction Code Set developed? | to achieve a higher quality of health care and reduce administrative costs |
| The numerous software programs formerly used by Medicare have been replaced by which single system? | Medicare Transaction System |
Created by:
FB