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MOP 110


Which is a typical responsibility of a health insurance specialist? Correcting claims processing errors.
Conduct and qualities that characterize a professional person are called.. Professionalism.
Health insurance specialists play an important role in the _________of denied or underpaid claims. Adjudication
It is the Health Insurance Specialists role to conduct all of the following except: Accurately diagnose and analyze documentation for medical necessity
The insurance and coding specialist calls a carrier to verify a patient's insurance and the representative states that the patient's insurance was canceled three months ago. which of the following should the insurance and coding specialist do first? Ask the patient for another form of insurance coverage
Which of the following must be verified to process a credit card transaction? (Select the three (3) correct answers). Security code, Account number, credit card number
When a patient calls to inquire about an account, which of the following does the insurance and coding specialist need to ask for before discussing the account? (select the three (3) correct answer). Patients date of birth, Patient's insurance ID number, and Patient's name
The provider is non-participating with the patient's insurance and the patient's insurance company states that they will cover 60% of allowed charges. The charge for the office visit is $100. The patient's copay is $10. Which of the following will the pat $50
A Medicare patient has an 80/20 plan. The charged amount was @300.00. The amount allowed was $100.00. Which of the following is the patient's coinsurance? $20
When should a provider have a patient sign an ABN? When the items may be denied and prior to performing the service.
The most effective method to manage patient statements and other financial invoices as well as avoid payment delays is to ______ Collect fees at the time of service
When following up on a denied claim, an insurance and coding specialist should have which of the following information available when speaking with the insurance company? (Select the three (3) correct answers). Date the claim was denied, Date of service, and Patient's insurance ID number
Which of the following is the most likely cause of the deposits not agreeing with the credits on the day sheet or the patient ledgers? Payment is misplaced
Which of the following financial reports procedures a quarterly review of any dollar amount a patient still owes after all insurance carriers claim payments have been received? Aging
An insurance and coding specialist is reviewing Appendix M in the CPT book. Which of the following tasks is she most likely performing? Checking for renumbered codes
A patient has called to schedule an appointment for an office visit to see the doctor tomorrow for an earache. It is discovered during the scheduling process that the insurance policy on file has been cancelled. Which of the following should the insurance Advise the patient to bring current information to the appointment.
Which of the following is an appropriate way to open the discussion when explaining practice fees to a patient? Do you have any questions about the cost for today visit?
Which of the following information is necessary to post payments from the RA/EOB? Select the three (3) correct answers). Date of service, Billed CPT codes, Patient's name
When there is a professional courtesy awarded to a patient's account the insurance and coding specialist should post the amount under the _________. Adjustment column
Which of the following must a patient sign prior to an insurance claim being processed? An Authorization to Release Information
Which of the following are necessary to complete a CMS 1500 form? (Select the three (3) correct answers). Physician information, Diagnosis and CPT codes, and Demographic information
Which of the following processes makes a final determination for payment in an appeal board? Adjudication
When patients sign Block 13 of the CMS 1500 claim to instruct the payer to directly reimburse the provider, it is known as ______. Coordination of benefits
Which of the following defines the maximum time that a debt can be collected from the time it was incurred or became due? Statue of Limitations
A patient presents for a right sided hip injection. The provider used palpation for guidance. Which of the following is the appropriate CPT* Code? 20610
The patient is sent a statement for an office visit. The total amount of the bill is $100.00 and this amount must be paid before the insurance company will pay on the claim. Which of the following is this called? Deductible
Collecting statistics on the frequency of copay collection at time of service is a step in the process of______ Managing A/R
Which of the following forms provides information from the Managed Care Organization that paid on the claim? EOB
If the insurance carrier's rate of benefits is 80%, the remaining 20%is known as______ Coinsurance
Co-insurance is typically due__________ After the claim has been adjudicated
HIPAA allows a health care provider to communicate with a patient's family, friends, or other persons who are involved in the patient's care regarding their mental health status providing_____. The patient does not object
The provider is paid the same rate per patient whether or not they provide services and no matter which services were provided. This payment is known as______. Capitation
Which of the following MCOs always requires an authorization before seeing a specialist? HMO
Which of the following fees posted to the patient's account is an example of "usual, customary, and reasonable?" Allowed amount
The patient's total charges are $300. The allowed amount is $150. Benefits pay at 60%. Which of the following will the patient have to pay? $60
The patient opted to have a tubal ligation performed. Which of the following is needed in order for the third party payer to cover the procedure? Letter of necessity
Which of the following reports is used to follow up on outstanding claims to third party payers? Aging
When a capitation account is applied to the ledger, it is also known as _______. Monthly premium
An established patient is being seen by the physician today. The patient owes $25.00 for the visit. The amount collected for the office visit is called the ______. Copayment
When posting an insurance payment via an EOB, the amount that is considered contractual is the______. Insurance allowed amount
Rules that govern the conduct of members of a profession are called Ethics
Which is another name for professional liability insurance? Errors and Omissions insurance
Physicians offices should bond employees who have which responsibility? Financial
Breach of confidentiality can result from? Discussing patient healthcare information with unauthorized sources
Which term describes an individual's right to keep healthcare information from being disclosed to others? privacy
The safekeeping of patient information by controlling access to hard-copy and computerized records is a form of____. Security Management
Excessive charges for services, equipment, or supplies is an example of Abuse
The recognized difference between fraud and abuse is the Intent.
When a Medicare provider commits fraud, which entity conducts the investigation. Office of the inspector General
As part of the administrative simplification provisions of HIPAA, which of the following unique identifiers is assigned to third party payer. National Health Plan ID (PLANID)
A dispute resolution process in which a final determination is made by an impartial person who may not have judicial powers is known as_______ Arbitration
The Stark Law was enacted to govern the practice of _____. Physician referrals to facilities that he/she has a financial interest in
Which of the following protects federal healthcare programs from fraud and abuse by healthcare providers who solicit referrals? Anti-Kickback Statute
The Fair Debt Collection Practices Act restricts debt collectors from engaging in conduct that includes ________. Calling before 8:00am or after 9:00pm, unless permission is given
Which of the following are violations of the Stark Law? (Select the two (2) Correct answers). Accepting gifts in place of payment from patients, and Referring patients to facilities where the provider has a financial interest.
When is a referral from a provider required? For Worker's Compensation patients
If the insurance and coding specialist suspects Medicare fraud, she should contact the _________. OIG
In order to have claims paid as quickly as possible, the insurance specialist must be familiar with which of the following? Payers claim processing procedures
An insurance and coding specialist is reviewing a patient's encounter form that is documented in the medical record prior to completing a CMS_1500 form. She notices that the physician upcoded the encounter form. The specialist has the ethical obligation t Query the physician
A third part payer made an error while adjudicating a claim. Which of the following should the insurance and coding specialist do? Resubmit the claim with an attachment explaining the error
If a provider refuses to accept assignment, when must the patient pay for services? Upon denial of insurance payment
Which type of HMO offers subscribers healthcare services by physicians who remain in their individual settings. Independent Practice Association
Provider services for inpatient medical cases are billed on what basis? Fee for services
Disability insurance typically provides what type of insurance to the injured person? Financial
A participating provider is one who enters into contract with a Blue Shield (BCBS) corporation and agrees to Bill patients for only deductible and copay/coinsurance amounts
TRICARE is a healthcare program for Active duty members of the military and their family members
Which act or amendment established an employee's right to continue healthcare coverage beyond a scheduled benefit termination date? COBRA of 1985
Which is a government-sponsored health program that provides benefits to low-income patients? Medicaid
The triple option plan can also be known as the cafeteria plan or a__________. Flexible benefit plan
The insurance industry is regulated by whom? Individual states
According to the national standards mandated by HIPAA for the electronic exchange of administrative and financial care transactions, which would be a covered entity? Managed Care Organization
The Worker's compensation First Report of injury form is completed when the patient first seeks treatment for a work-related illness of the injury
The filing deadline for the First Report of injury form is determined by state requirements
Worker's compensation premiums are paid by the Employer
The Veteran Healthcare Expansion Act of 1973 authorized the Veterans Affair (VA) to establish to provide healthcare benefits for dependents of veterans rated as 100 percent permanently and totally disabled as a result of service-connected conditions, and CHAMPVA
What is COBRA? Provides medical insurance to employees that have lost their jobs
The insurance and coding specialist is billing the insurance company of a 66-year-old woman who has Medicare and is covered under her husband's private insurance. Which of the following should be billed first? Medicare
If a married couple is covered both spouse's health insurance and the husband wishes to schedule an appointment for an annual exam, he should call his primary care provider and ______. Schedule an appointment using both his insurance benefits and his wife's insurance benefits
A Medicare patient presents to an outpatient hospital facility for a scheduled hysterectomy. To which Medicare plan should the facility submit the claim? Part B
Base on the CMS manual system, when updating or maintaining the billing code database, which of the following does the "R" denote? Revised
Collection agencies are regulated by the_____. Fair Debt Collections Practice Act
Which of the following patient information is needed to determine a Medicaid sliding fee scale? (Select the three (3) correct answers). Number of dependents, Poverty level, and Salary
Encounter forms should be audited to ensure the ______. Diagnosis is proper ICD_10_CM format
Which of the following regulations prohibits the submission of a fraudulent claim or making a false statement or representation in connection with a claim? Federal False Claims Act
Which of the following is the correct procedure for keeping a Worker's Compensation patient's financial and health records when the same physician is also seeing the patient as a private patient? Separate financial and health records must be used
Which of the following federal regulations requires disclosure of finance charges, late fees, amount, and due dates for all payment plans? Truth in Lending Act
Data entry of insurance information is important because______ are rejected by insurance companies if data is missing or erroneous. Claims
When is it appropriate to file a patient's secondary insurance claim? After the remittance advice is received by the medical practice
Practices that submit paper insurance claims obtain the patient's signature in block 12. Block 12 on the CMS_1500 claim form represents which of the following pieces of information? Release of information
What is another name for an encounter form? Superbill
What is the most common medical documentation format? SOAP
What does the abbreviation CHEDDAR stands for? C-Chief Complain, H-History of present illness, E-examination, D-details of problems and complaint, D-drugs and dosage, A-assessment, R-return visit or referral to a specialist
What is an PNI? A standardized identifier for all healthcare providers
When posting transactions for electronic claims submission, it is necessary to enter which of the following items onto the claim? Physician's office fee
Which of the following forms should be transmitted to obtain reimbursement following a physician's office visit for a patient which active Medicaid coverage? CMS-1500
A claim submitted with all the necessary and accurate information so that it can be processed and paid is called a ______. Clean Claim
Claims are often rejected because a provider needs to obtain___. Pre-authorization
When filing an electronic insurance claim, the insurance and coding specialist processes which of the following forms? CMS-1500
Developing an insurance claim begins______. When the patient calls to schedule an appointment
A patient has two health insurance policies - a group insurance plan through her full-time employer and another group insurance plan through her husband's employer. Which of the following policies should be billed as primary? Her policy
Created by: frla5938