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Group 5 & 6

Medical billing and coding ashworth

___ feedback from the insurance company documenting the progress of individual claims that have been submitted. audit/ edit report
___ a 3rd party agency outside of the hospital or physicians practice that is responsible for submitting claims billing services
___ determines which insurance is primary when 2 policies are valid for a child. birthday rule
__ a completed insurance claim form submitted with the program time limit that contains all the necessary information without deficiencies so it can be processed and paid promptly. clean claim
___ a claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment dirty claim
___ any medicare claim that contains complete necessary information but is illogical or incorrect. invalid claims re identified to the provide and may be resubmitted invalid claim
___ a rejected claim is an electronically submitted claim that is unprocessable due to missing or invalid information required by the payer. rejected claim
___ a group that takes nonstandard medical billing software formats and translates them into the standard electronic data interchange (EDI) formats is called? clearing house
___ developed by the ama and the centers for medicare & Medicaid services (CMS). used by physicians and other professionals to bill outpatient services and supplies to Tricare. cms 1500 universal claim form
___ when a patient has more than 1 insurance policy, insurance carriers work together to coordinate so the maximum payment does not exceed 100% coordination of benefits (COB)
___ an insurance claim submitted on paper, including those optically scanned and converted to an electronic form by the insurance carrier. paper claims cms-1500
__ an insurance claim submitted to the insurance carrier via a central processing unit (CPU), tape, diskette, direct data entry, direct wire, dial-in telephone, digital fax, or personal computer download or upload. electronic claims
___ process of scrambling information during the time it is being transmitted by rotating letters in the alphabet and/or numbers encryption
___ a #'s issued by the internal revenue service to any medical facility, provider, or business for tax purposes. employer identification # (EIN)
___ A #'s issued to a facility and used by a physician to report services provided at a particular location. facility provider # (FPN)
__ the boxes located on the ub-04 & cms-1500 claim forms form locators
__ a # assigned to a group for billing purposes group provider # (GPN)
___ person who is responsible for a patients debit is called guarantor
__ forms that contain demographic employment, and insurance info about a patient patient information form
___ specifies which information can be released and to who. release of information form
__ unique identification # issued by the state for billing purposes state license #
__ with regard to works compensating claims, benefits that may be issued to an injured worker due to the percent of impairment rating, or if the worker has not been able to find employment that matches his or her ability to work supplemental income benefits
__ medicare beneficiaries can also obtain supplemental insurance called? medigap
___ identification # used by the internal revenue service in the administration of tax laws. tax identification # (TIN)
__ form used to identify & record the benefits a patient has w/ the insurance company by services are rendered verification of benefits form (VOB)
__ the doctor responsible for admitting a patient to a hospital or other inpatient health facility admitting physician
__ prospective payment system patterned after that of ambulatory patient groups. AOCs are used for outpatient services, and partial hospitalization. this payment method is based on procedures rather than diagnosis ambulatory payment classification (APC) system
___ facility designed for patients receiving minor surgery. in & out ambulatory surgical center (ASC)
___ facility w/in a hospital for patients receiving minor surgery. in ambulatory surgical unit
___ physician primary responsible for medical care attending physician
___ a database that contains a detailed narrative of each procedure, service, dollar amount, and revenue code that is used in inpatient facilities. charge description master
__ one or more diseases or disorders that present in addition to the primary disease or disorder comorbidity
___ medical services rendered for extenuating circumstances that can not be assigned to a diagnosis related group cost outliner
__ medical care necessary to sustain life and limbs emergency care
___ a computer software program that abstracts data from a medical record and assigns the DRG payment group. grouper
___ palliative care for a person who is dying hospice
___ conditions patients may get during an inpatient hospital stay. hospital acquired conditions (HAC)
___ identifies all patient who have been treated In a facility or hospital, and lists the medical record or identification # associated with each patient. master patient index
___ care provided to a patient who is in the hospital for 24+ hours inpatient care
___ a period of time during which medical benefits are available to an insurance beneficiary benefit period
___ contains provisions giving former employees right to temporary continuation of health coverage for 18 months after employment has ended. consolidated omnibus budget reconciliation act 1985 (cobra)
__ an electronic notification sent to the provider who accepts assignment electronic remittance advice (ERA)
__ a numeric & alphabetic coding system/ standard code set used for billing / pricing of procedures healthcare common procedure coding system (HCPCS)
__ a private company that has a contract with Medicare to pay part a & b intermediaries
___ the maximum amount a non-participating physician can charge a medicare patient on a non-assigned claim limiting charge
___ improper payments for items or services when there was no legal entitlement to the payment. medicare abuse
___ previously referred to as fiscal intermediaries and carrier, entities, awarded contracts by CMS to adjudicate and pay medicare claims medicare administrative contractor (MAC)
What does mac stand for? medicare administrative contractor (MAC)
___ is hospital insurance provided by medicare. Most people do not pay a premium for this coverage medicare part a
___ is a medical insurance to pay for medically necessary services and supplies provided by medicare. medicare part b
___ is the combination of part a and part b. The main difference is part c is that it is provided through private insurance companies approved by medicare medicare part c
___ is stand-alone prescription drug coverage insurance medicare part d
___ free or low cost health insurance coverage through the state medicare
___ knowing and intentionally executing a plan to scheme or defraud any healthcare benefit program medicare fraud
___ notice sent to providers, details how a claim was processed. medicare remittance notice (MRN)
___ any situation in which a payer is required by federal law to pay before medicare pays medicare secondary payer (MSP)
___ an easy to-read document that clearly lists the health insurance claim info medicare summary notice (MSN)
___ is a professional claim for professional services cms-1500
____ is an institutional claim form hospital service cms-1450
__ amount that applies to unassigned services performed by physicians/ suppliers who choose not to participate in the medicare program non-par MFS
___ the largest inspector generals office in the federal government office of inspector general (OIG)
__ audits the processed claims by MAC and recovers improper paid claims recovery audit contractor (RAC)
___ A time-limited (5 years) cash assistance benefit for families that qualify based on a state income or poverty level. Tax relief and health care act (TRHCA)
___ hospital insurance medicare part a
__ supplemental medical insurance coverage medicare part b
__ additional services medicare part c
___ coverage for prescription drugs medicare part d
__ The Medicaid eligibility group that includes cash recipients of aid to families with dependent children (AFDC)-now known as temporary assistance to needy families (TANF), most cash recipients of social security income (SSI) and certain of groups categorically needy
___ A program that provides health insurance to all uninsured children and teens who are not eligible for or enrolled in medical assistance children's health insurance program
___ Program that specifies the formula for calculating federal medical assistance percentages. federal medical assistance percentages (FMAP)
___ Allows states to extend Medicaid eligibility to additional qualified persons who may have to much income. they can receive medical services, but not cash assistance medically needy
__ Term used to refer to a beneficiary who is covered under the medicare program but is also eligible for coverage through the Medicaid program medi-medi
___ your other insurance will be billed and pay before medicare. payer of last resort
___ must see a designated physician or pharmacy restricted status
___program that allows patients to pay a portion of medical expenses each month. spend-down program
___ government program funded by taxes, that helps pay living expenses for law income older people, blind or disabled supplemental security income (SSI)
__ limits the amount of out-of-pocket expenses a family will have to pay for Tricare covered medical services Catastrophic cap
___ the amount of healthcare charges that are the responsibility of the sponsor or family member cost share
___ health care program for uniformed service members, retirees and their families Tricare
___ option that provides the most flexibility to Tricare-eligible beneficiaries. it is the fee-for-service option gives beneficiaries the opportunities to see any Tricare-authorized provider. Tricare standard
___ A preferred provider option, rather than annual fee, a yearly deductible is charged. health care is delivered through a network of civilian health care providers who accept payments from champus and provide services at negotiated, discounted rates Tricare extra (PPO)
__ an hmo type plan in which enrollees receive health care through a military treatment facilities pcm or supporting network of civilian providers. Tricare Prime (HMO)
___ Claim processor for Tricare's northern region of the us palmetto government benefits administrators (PGBA)
___ Physician who coordinates and manages a Tricare prime patient care Primary care manager (PCM)
__ The beneficiary or policy holder of a Tricare plan Sponsor
___medicare- wrap around coverage available to all medicare-eligible Tricare beneficiaries, provided they have medicare part a & b. Tricare 4 life (TFL)
___ a health care plan that is available to active-duty members who are stationed more than 50 miles from home. Tricare prime remote (TPR)
___ a worldwide health plan that qualified retired reserve members and survivors may purchase. Tricare reserve retired (TRR)
__ serving active-duty service members Tricare reserve select (TRS)
__ for beneficiaries 65+ Tricare senior prime
___ premium-based healthcare plan that qualified dependents may purchase Tricare young adult (TYA)
___ claims processor for all Tricare senior prime claims Wisconsin physicians services (WPS)
__ insurance policy that pays benefits in the event that the policy holder becomes incapable of working Disability insurance
__ helps cover costs not reimbursed by the original medicare plan Medigap
when does the tertiary insurance pay? after the primary and secondary insurers
___ involves restricting patient info access to those with proper authorization and maintaining the security of patient info confidentiality
everything a medical claims specialist learns about a patients condition must remain ___ confidential
What does policy mean? insurance
A person who receives a check in payment is the ___? payee
Insurer/insured, subscriber, member, recipient are all terms that apply to the ____? policyholder
T/F preferred provider organizations (PPO) never allow members to receive care from physicians outside the network. false (policy holders may choose to go out of network, but they have to pay more.)
___ is a job benefit that provides money and services to employees that are injured or become sick on the job. work's comp helps injured and sick workers to survive financially as they recover from health problems workman's comp
__ the payment amount for each service paid under the physician fee schedule is the product of three factors; a nationally uniform relatives value for service; a geographic adjustment factor (GAF); a nationally uniform conversion factor for the service relative value payment method
__ the schedule assigns certain values to procedures/costs based upon total RVUs. The total consists of 3 components work, practice expenses & malpractice. medicare adjustments payments by geographic price cost index (GPCI) and pays depending on locale. medicare resource based relative value unit (RVU)
also known as federal tax identification number EIN
provider identification number, issued by the carrier PIN
national provider identifier issued by cms. NPI
member of a group practice who submits claims under the groups name GPN
denotes signature on file SOF
emergency EMG
health insurance claim HIC
last menstrual period LMP
# issued by the internal revenue service for income tax purpose TIN
a facility provider number used by the performing physician to report services done at that location FPN
The ___ manager is the provider who coordinates care of Tricare beneficiaries primary care
the worldwide database of Tricare and CHAMPVA beneficiaries is ___ DEERS
The Tricare fiscal year begins __ and end ___ Oct 1, Sept 30
Third level of medicare appeal administrative law judge hearing (ALJ)
chronological recording of pertinent facts and observations regarding a patients health status in a logical sequence documentation
A written request for a review of reimbursements claim appeal
an objective, unbiased group of physicians who determine what payment is adequate for services provided peer review
The regulatory agency for the insurance industry, services as a liaison between the patient and the carrier insurance commissioner
a method of documentation most widely used by physicians for record keeping SOAP
a process of examining and verifying claims and supporting documents submitted by a physician or medical facility audit
Having a patient’s billing information available almost immediately after treating a patient is an advantage of A. EMCs. B. HITECH. C. CMS-1500. D. OCR. b
If a patient isn’t being seen on an emergency basis, what should be entered in the EMG form locator? A. “No” B. “–” C. “N/A” D. Nothing; leave it blank. d
You’re speaking with a patient’s insurance carrier who refuses to pay the claim even though the physician’s office provided all of the correct information. Which form could you refer to in the patient’s record? A. COB B. VOB C. FPN D.GPN b
With the incoming ICD-10 changes, which one of the following choices is proposing changes to the CMS-1500? A. NUCC B. CMS C. HITECH D. AMA a
You work for a company that provides claims processing for physician offices. You may work for a(n) A. guarantor. B. CPT office. C. FPN. D. billing service. d
If the Medicaid resubmission number is missing on the CMS-1500, what should you do? A. Deny the claim. B. Telephone the employer for the missing information. C. Enter the correct information in form locator 22 D.Leave form locator 12 blank c
Which one of the following choices requires that those who transmit and store information electronically use a process of scrambling the information? A. HITECH B. HIPAA C. CMS D. OCR b
claim was reject cuz the insur# on the CMS1500 was entered incorrectly. What could prevent this A.Submit a claim w/ the FOB to the 2nd carrier B.copy front&bac of the insurance card C.phone the patient to get the info D.Provide a CLIA on the NPI b
Which one of the following choices is an advantage of EMCs? A. It increases the number of patients. B. It decreases the chance of errors. C. It increases payments for paper claims. D. It decreases the number of insurance carriers billed b
Jane K. Doe is the patient and the insured. What should be entered in form locator 4 on the CMS-1500? A. Jane K. Doe B. Doe, Jane C. Same D. Patient c
A patient is seen in a birthing center. Which place-of-service code may be noted on the CMS-1500? A. 11 B. 20 C. 25 D. 31 c
Which one of the following choices is the correct way that an address would be entered on the CMS-1500? A. 123 Maple Street Apartment A B. 123 Maple St, Apartment A. C. 123 Maple Street, #A D. 123 Maple St. Apt. A a
Which one of the following items would you probably not find on a routing slip? A. ICD-9-CM/ICD-10-CM codes B. CPT codes C. Patient’s name D. Patient’s insurer d
When an insurance company is asked to send the payment directly to the physician instead of the patient, it’s referred to as A. release of information. B. verification of benefits. C. assignment of benefits. D. the superbill. c
You’re documenting a patient’s employer on the CMS-1500. Which one of the following form locators would you complete? A. 1a B. 10 C. 11b D. 16 c
Electronic transmission of information standards, such as transaction and code sets and uniform identifiers, are covered under A. administrative simplification. B. HITECH. C. CMS. D. OCR. a
Jimmy is a 12-year-old boy who is seeing the doctor for a school checkup. He’s with his mom and his 18-year-old brother. Who is most likely the guarantor? A. Jimmy B. Jimmy’s mom C. Jimmy’s brother D. Jimmy’s doctor b
U just moved to another state to work 4 a new physician. W/ whom should u check to ensur that u understand the billin requirements 4 ur new state? A.CMS B.Medicare C.Local intermediaries D.clearinhouse c
You’re training a new employee about the CMS-1500 form. The employee calls the information input areas “fields.” You correct her by saying they’re called A. form locators. B. coordination of benefits fields. C. PINs. D. EINs. a
A physician’s office needs more claim forms. Which one of the following choices could it contact? A. HIPAA B. HITECH C. AMA D. CMS c
Dr. Brown was the referrin, Dr. Jones was the supervisin&Dr. Smith who was the orderin provider In what order r the physicians listed on the CMS1500 A.Doe, Brown, Smith, Jones B.Brown, Smith, Jones C.Jones, Brown, Smith D.Smith, Brown, Jones, Doe b
You notice that a patient’s first name is misspelled on the CMS-1500 form. What should you do? A.Change it to the correct spelling immediately B.Wait until the patient presents an insurance card C.Complete a Change of Name form&hold the bill until veri b
On the CMS-1500, the insured person’s signature may be indicated by which one of the following designations? A. “Same” B. “Self” C. “SOF” D. “Yes” c
Jane Doe has insurance through her work, but is also covered under her husband’s insurance. Her husband’s insurance may be referred to as the A. secondary insurance. B. coordinating insurance. C. primary coverage. D. explanation of bene a
A child lives with both of his parents and is covered under both of their insurance plans. How do you determine which insurance is the primary insurance? A. Refer to the COB. B. Call the insurance carrier. C. Use the birthday rule. D. L c
Which one of the following individuals would use a FECA number when completing a CMS-1500? A. Government employee B. Hospital employee C. Student D. Child a
A physician’s office just saw a new patient but can’t submit a claim to the patient’s insurance. Which one of the following choices might be a reason for this? A. The patient is the guarantor. B. There is no secondary insurance listed in the pati d
Which one of the following choices may be cause for a claim to be marked as a dirty claim? A. The patient’s birthdate is missing. B. The physician tried to knowingly bill for more than the service provided. C. A claim attachment wasn’t submi a
A patient sees a provider for CHF. The provider will be reimbursed based on an expected amt to treat the CHF. The provider is bein reimbursed based on which system? A.Perdiem B.Ambulatory pmt classification C.Fee-for-service D.Prospective pmt d
On the CMS-1450, what should you enter for inpatients in form locator 46? A. Units B. HCPCS codes C. Days D. Charges c
Which one of the following choices is considered a major revenue code category on the UB-04? A. Hospice B. Home care C. Vitamins D. Physical therapy d
A hospital’s CDM hasn’t been changed for the past year. Which one of the following outcomes could result from this? A.Improvement in the cost-of-living reimbursement B.Overpayment of claims C.Increase in the # of admissions D.Assign of procedure codes b
A hospital coder unethically assigns codes that are more severe than the patient’s true diagnosis to receive more reimbursement. This act is known as A. upcoding. B. rendering. C. correlating. D. downcoding. a
If you wanted to look at all of the patients in a hospital, you could access the A. PAS. B. MPI. C. PCN. D. HAC. b
In the type of bill code example of 0123, which number indicates the sequence of the bill for this hospitalization? A. 0 B. 1 C. 2 D. 3 b
For a Medicare patient, what happens when information is entered in form locator 72? A. Medicare ignores it. B. It increases reimbursement. C. Medicare puts it into an injury database. D. It is matched to revenue codes on the CDM. a
Which one of the following choices is a payment system based on procedures that group together services? A. DRGs B. PPO C. APC D. HCPCS c
Which one of the following form locators is not required by Medicare? A. Provider name and address B. Type of bill C. Patient name D. Patient control number d
Which one of the following choices is not considered a major section for the UB-04? A. Prescription information B. Payer information C. Dependent information D. Treatment information b
Which one of the following choices usually increases a patient’s length of stay and may have a negative effect on the treatment? A. DRG B. Comorbidity C. Prognosis D. APC b
In the form locator for prior payments, what should you do when you have prior payments from other carriers? A. Attach the Explanation of Benefits. B. Include the 10-digit NPI. C. Enter the applicable code for the insured. D. Enter “9.” a
Many hospitals converted to electronic health records to A. save money. B. serve more patients. C. comply with HITECH. D. bill for Medicare patients. c
A disabled child has insurance through his father’s employer. Which one of the following codes might be used on the CMS-1450 to indicate the relationship to the insurer? A. 18 B. 19 C. 22 D. 33 c
Which one of the following items on the inpatient record could cause an increase in reimbursement? A. CMS B. CC C. PCN D. ASU b
Which one of the following choices pays actual charges based on treatment given to a patient? A. Prospective payment B. Fee-for-service C. Per diem D. Outpatient prospective payment b
What is the maximum number of services that can be billed on one UB-04? A. 25 B. 22 C. 15 D. 7 b
Services listed with the corresponding HCPCS and revenue codes can be found on the A. CDM. B. CPT. C. PCN. D. POA. a
For reimbursement, Medicare determines a covered period for a patient by looking at which form locator? A. 15 B. 11 C. 51 D. 17 d
A patient has been denied the private insurance that covers the things that Medicare doesn’t. Which 1 of the followin may b y? A.makes too much money B.unmatched diagnoses on his claims C.hasn’t chosen a primary care physician. D.enrolled in an HMO d
Which one of the following choices provides states grants to spend on cash assistance? A. CHIPRA B. SCHIP C. CHIP D. TANF d
A Medicare Part A patient has been hospitalized for 72 days. For how many of those days will the patient need to pay coinsurance? A. 0 B. 12 C. 60 D. 72 a
A mother and child are both covered under the father’s TRICARE insurance. What should be entered on form locator 1a for the claim form? A. The child’s Social Security number B. The father’s Social Security number C.mother’s SS# D.Nothin b
A patient needs assistance for paying for her medications. Which one of the following choices might she use? A. Medicare Part A B. Medicare Part B C. Medicare Part C D. Medicare Part D d
What is 1 benefit of adding MN to the Medicaid program? A.program to receive more reimbursement from the state government. B.states to cover additional people under Medicare. C.more physicians to be reimbursed under Medicaid. D.Medicare patients t b
A TRICARE patient needs to be treated at a civilian facility because of the specialized treatment provided there. What’s the patient’s first step? A. Receive a NAS. B. Check with the DEERS. C. Request prospective reimbursement information fr a
Which one of the following choices is a service that states can choose to offer under Medicaid? A. Prenatal care B. Vision coverage C. Vaccinations D. Blood tests b
If a patient’s claim is being reimbursed based on the RBRVS, the patient probably has which type of plan? A. MediMedi B. Medigap C. Fee-for-service D. Managed care a
A Medicare patient needs a hearing aid. Which one of the following choices will most likely cover the hearing aid? A. Medicare Part A B. Medicare Part B C. Medicare Part C D. Medicare Part D c
Which one of the following choices assigns a person to help coordinate and manage a patient’s medical care? A. TRICARE Standard B. TRICARE Prime C. TRICARE Prime Remote D. TRICARE Extra b
A patient over age 65 was admitted to the hospital for a hip fracture and surgery. Which one of the following choices is probably the patient’s primary hospital insurance? A. Medicare Part A B.Medicare Part B C.Medicare Part C D. Medicare Part D a
A Medicare patient made $97,000 at his job in 2012. How much will he pay for his Medicare Part B premium? A. $0 B. $99.90 C. $139.90 D. $199.90 d
A patient has Medicaid plus another insurance. How should Medicaid be billed? A. As the primary insurer B. As the secondary insurer C. As the only insurer D. It depends on the other insurance. a
Review the completed TRICARE claim form (Figure 15.3) on page 454 of your textbook. What was the disease or illness code that brought the patient in for treatment? A. 99212 B. 251.2 C. 80053.90 D. 36415 b
You work in a physician’s office and are reviewing detailed information on the coding and medical necessity of the services the physician provides. You are probably reviewing a(n) A. MRN. B. CMN. C. MSN. D. LCD. b
A patient has a spenddown level of $200 each month. What does this mean? A.must spend that amount each month before she’s covered B.reimbursed only $200 C.reimbursed only on claims greater than $200 D.can bill the patient only $200 c
Which one of the following choices is used for permanent military personnel who aren’t near any treatment facilities? A. TRS B. TFL C. TPR D. TYA a
Which one of the following refers to when the federal government reimburses each state for a % of its medical costs? A.Temporary Assistance for Needy Families B.Social Security modifier C.Supplemental Security Income D.Federal Medical Assistance % d
An active duty military member has TRICARE. Under the program, this person is called the A. insured. B. TPR. C. DEERS. D. sponsor. d
Which one of the following is an ex. of Medicare fraud? A.nonparticipating physician treats Medicare patients B.no effort to collect coinsurance for Medicare patients C.files Medicare claims on a daily basis D.refuses to treat Medicare patients b
doc wants to start seein Medicaid patient and receive reimbursement. Whats import to no A.diag codes are diff B.submitted on the 1&15 of each month C.can’t be billed 4 additional pmt after pmt is received D.adhere to AMA certi guidelines a
A Medicaid patient has a primary care physician whom she must go through if she needs to see a specialist. This patient is working under which Medicaid model? A. PCCM B. PHP C. RAC D. TEFRA a
Which one of the following form locators helps the person posting insurance payments for the office? A. ID Number of Referring Physician B. Reserved for Local Use C. Patient’s Account Number D. ID Qualifier c
Which one of the following choices is the DOD medical entitlement program? A. TRICARE B. PCCM C. MTF D. DEERS a
A patient is in home health care for medically necessary reasons. How long will Medicare Part A cover home health care for the patient? A. 30 days B. 60 days C. 90 days D. As long as necessary d
When filin a Medicaid claim y would u leave the form locator for Other Insureds Name blank? A.the payer of last resort B.need a verification # for the other insured C.office doesn’t work with that field D.patient doesn’t have his Medicaid paperwork b
Which one of the following choices was implemented, in part, to help determine errors by FIs? A. CMS B. MMA C. RAC D. SNF a
A baby was just born to a mother who is on Medicaid. The baby may be considered to fall under which one of the following categories? A. Medically Needy B. Categorically Needy C. Special Group D. FMAP a
A patient is covered under MediMedi. Which one of the following choices will be billed first? A. Medicare B. Medicaid C. MediMedi D. Patient c
Which one of the following benefits helps children and adolescents age 21 and under? A. FQHC B. PACE C. EPSDT D. ABN b
On the “Medicaid Resubmission Code” form locator, what should be entered when filing a TRICARE claim? A. “X” B. “Y” or “N” C. The provider ID number D. Nothing c
Which one of the following individuals is eligible for Medicare hospital insurance? A.7-year-old healthy child B.34yo wife of a man enlisted in the army C.12yo girl receiving dialysis 4 end-stage renal disease D.67yo man who has never paid FICA a
What role does PGBA play in TRICARE? A. It’s the claim’s payer for a portion of the United States. B. It makes annual updates on reimbursement fees. C. It approves enrollee eligibility for the military. D.adjudicates the claim for Medicare a
The decision of whether or not to reimburse Medicare payments to physicians who are noncompliant can be made by A. AMA. B. LCD. C. DHHS. D. LMP. a
You’re completing the claim for a Medicare Part B patient. What should be entered on form locator 17a? A. The referring physician’s name B. The referring physician’s number C. The referring physician’s name and number D. Nothing c
A Medicare patient wants to have his claims sent to his Medigap insurer through a notification on the claim. This reassignment is known as A. crossover. B. upcoding. C. advanced beneficiary notice. D. copayment. b
Which one of the following choices processes all claims for TFL? A. CHAMPUS B. CMS C. TRICARE D. WPS c
Civil penalties in addition to triple damages can be imposed on providers who A.refuse to work with patients B.only accept Part A patients & no other C.r found in violation for Medicare abuse or fraud D.cant participate in supplemental insurance plans c
Which one of the following is a responsibility of a MAC? A.Puttin new healthcare legislation in place B.Keepin records on the quality of Medicare providers C.Creatin SNF day requirements 4 reimbursement D.Providin annual updates 4 AT billing modifiers c
___ the insurance carriers process of evaluating a claim for payment adjudication
___ a positive or negative change to a patients account balance adjustment
___ maximum amount an insurance payer considers reasonable for medical services allowed changes
___ the process used by a provider to ask an insurance carrier to reconsider a denied claim appeal
__ contract that a provider signs with a carrier agreeing to treat so many members capitation plan
___ fees providers routinely charge for medical procedures performed charge based fees
___ billing patients for the dollar amount left over after insurance has paid balance billing
___ a dollar amount used to multiply relative value units (RVU) in order to arrive at the price of a service conversion factor
___ an electronic notification sent to provider who accepts assignments electronic remittance advice (ERA)
___ services not covered by an insurance payer as stated in the insurance policy excluded services
___ an adjustment that accounts for geographic variations in the costs of practicing medicine in different areas of the country geographic practice cost index (GPCI)
___ as stated in the insurance policy, the maximum amount of money a plan will pay toward health care services over the life time of the insured lifetime maximum
__occurs when a claim is removed from an automated claims processing system and sent to a claims examiner to request additional information in order to complete the processing of the claim manual review
___ based on the resource based relative value scale (RBRVS) fees. This amount is the most medicare will allow to be paid for a procedure. medicare fee schedule
___ determined by centers for medicare and Medicaid services, the MCF is a national value that converts the total relative value units into a payment amount to reimburse providers for medical services medicare conversion factor (MCF)
__a standardized scale, based on 3 cost elements; the physicians amount of work to acnt 4 each service, the practice cost associated w/ deliverin the service, and the pro liability insurance to cover the procedure bein performed. used as a basis for fees nationally uniform relative value
___amount of healthcare expenses for which a policy holder or patient is responsible. the amount is determined by the payer and is listed in the insured policy. the payer reimburses services at 100% once the out-of-pocket expenses are met in a calendar yr out-of-pocket expenses
__ a claim that has been received by the carrier but has not yet been processed. usually additional information is requested from the provider to continue processing of the claim. pending claim
___ refers to the fees paid on a capitation plan. the rate is based on a list with a # of members sent to the provider at the beginning of the month. the provider is paid up front for medical services rendered whether the patients are treated or not. per member per month (PMPM)
___ # or alphabetic digits that indicate the reason why claim was not paid full, how the claim was calculated or why the claim was denied. also known as remarks codes reason codes
___ unit of measure assigned to a medical procedure based on the time required to perform it. This system is composed of 3 elements work, practice expense, and liability insurance. relative value unit (RVU)
___ fees based on resource-based relative value scale (RBRVS) resource based fees
__ a payment schedule system that represents the resources used to perform a procedure or service by assigning a relative value for each procedure resource-based relative value scale (RBRVS)
__ determines how long patient records must be stored. this determination is based on state regulations and federal laws retention schedule
___ length of time an insurance carrier takes to process a claim from the time it is received in the carriers office turn around time
__ a fee determined by 3-party payers to reimburse providers based on the providers normal fee, the range of fees charged by providers of the same specialty in the same geographic area, & other factors to determine appropriate fees in unusual situations usual, customary, and reasonable (UCR)
under a capitation plan, this is a % of the providers payment that is deducted from the check to offset any additional costs. at the end of the year, any withhold not used is distributed as a bonus. withhold
__ negative adjustments to patient accounts. usually when the provider has contract with a carrier, the difference between the billed amount and the allowed amount is written off write-offs
__ the 3rd level of appeal for physician claims w/ medicare. physicians have 60 days to file an appeal. medicare must make a decision within 90 days. administrative law judge (ALJ) hearing
___ a consistent medical record format, often in chronological order, that records facts & observations regarding a patients health status documentation
___acknowledgement to an employee that the workers compensation claim has been accepted or approved admission of liability
___ benefits paid to the person who pays a deceased workers funeral expenses burial benefits
__ benefits that can replace a position of lost family income for eligible family members of death benefits
___ a physical or mental handicap especially one that prevents a person from holding a gainful job disability
__ programs that reimburse a covered individuals for wages lost due to a disability that presents the individual from working disability compensation programs
___ with regard to workers compensation claims, permanent physical damage to a workers body from a work related injury or illness impairment
___ benefits paid to an injured worker if the injury worker is found to have permanent impairment from a work-related injury or illness impairment income benefits
___ benefits that injured worker becomes eligible for from the date of disability if the injury is the loss of both feet at or above the ankle; the loss of both hands at or above the wrist; the loss of one foot or above the ankle; lifetime income benefits
__ with regard to workers compensation claims the point in time at which an injured workers injury or illness has improved as much as it is likely to improve maximum medical improvement
___ in the context of workers compensation, medical care that is reasonable and necessary to treat a work related injury or illness medical benefits
___ with regard to workers compensation claims notice issued to an employee if his or her employer denies a workers compensation claim. notice of contest
___ health problems that are the direct results of workplace health hazard such as dust, gas, and radiation. these can come on rapidly or develop over time occupational diseases and illnesses
___ act that gave the federal government the authority to set and enforce safety and health standards for most employees in the unites states; administered by the occupational safety and health administration occupational safety & health act
__ federal agency the over sees the federal laws requiring employers to provide employees with a workplace free from hazardous conditions occupational safety and health administration (OSHA)
___ with regard to workers compensation claims, benefits that may be issued to an injured workers due to the percent of impairment rating, or if the worker has not been able to find employment that matches his or her ability to work supplemental income benefits
__ a representative of workers compensation insurance plans who can assist the injured worker with the workers compensation claim at no charge. the ombudsman is not a lawyer but know the law as it pertains to workers compensation claims ombudsman
___ with regard to workers compensation claims, benefits a worker may receive if an injury or illness caused the worker to lose some or all income for 7 days. temporary income benefits
__ the task of entering a charge, payment, or adjustment on a patents account transactions
__ with regard to workers compensation claims doctor who treats the injured worker; also know as the physician of record treating doctor
___benefits paid to a veteran because of injury or disease that happened while on active duty or were made worse because of active military service veterans disability compensation
__ benefits paid to wartime veterans with limited income who are no longer able to work veterans disability pension benefits
__ The retraining of an employee so he or she can return to the workforce vocational rehabilitation
state workers compensation plans include 3 components medical expense coverage disability pay vocational rehabilitation
4 types of workers compensation benefits include? medical income death burial
income benefits are broken down into additional categories temporary income benefits impairment income supplemental income lifetime income
__ The process used by a medical offices specialist to calculate all monies received, tally all cash on hand and compare the totals w/ the patients day sheet batching out
__ amounts a practice charges for medical services rendered charges
__ medical software data base used in medical practices that stores physicians charges, patient data, adjustment information, and demographical and other information within a medical practice medical practice management (MPM) software
__ patient info verify ins. prepare encounter form. code dx & cpt, review linkage protocol, calculate physicians charges, prepare claim, transmit claim, follow up on reimbursement basic billing reimbursement steps
__ appropriateness of codes, payers rules about linkage. documentation to support codes, compliance with regulation and guideline review linkage protocol
__ submission, processing, adjudication, non covered, unauthorized, medical necessity checks, payment/ ra/era life cycle of claim
__ What simplified process was developed to enable medicare beneficiaries to participate in mass pneumococcal pneumonia virus (PPV) and influenza virus vaccination programs offered by public health clinics roster billing
__ A person filling an appeal is called? claimant
___ covers injuries caused by insured that occurred on the insured's property liability insurance
A detailed accounting of the claims for which payment is being made by an insurance company. the ___ accompanies the payment from the insurance company. remittance advice (RA)
__ A severe form of hypertension with vascular damage and a diastolic pressure reading of 130 mm hg or greater. malignant
___ mild and/or controlled hypertension, with no damage to the patients vascular system or organs benign
__ no notation of benign or malignant status is found in the diagnosis or in the patients chart unspecified
__ for inpatient coding, the initials cc mean comorbidities & complications
Contain full description to the procedure for a code is? stand alone codes
__ e&m anatomical site, condition or disease, synonym or eponym abbreviation six sections of cpt
1. history 2. physical exam 3. medical decision-making 3 components for em codes
category 1: procedures that are consistent with contemporary medical practice and are widely performed. Category 2: supplementary tracking used to performance measure. category 3: temporary codes for emerging technology services & procedures 3categories for em codes
new or existing patient, history, physical exam, medical decision making, time specnt can be a 5th factor. 4 contributing factors for em codes
___ comprehensive health care program with the va shares the cost of covered health care services and supplies with eligible beneficiaries champva
Private individuals are responsible for securing their own health insurance coverage. commercial government, employer, group health insurance coverage private payer vs commercial payer
__ an insurance plan that provides healthcare coverage to select group of people. group health insurance plans are one of the benefits offered by many employers. these are generally uniform in nature, offering the same benefits to all members of group. group health plans
health indemnity insurance is a fee for service insurance that is sometimes used when a person is in between health plans, and will cover some but not all expenses indemnity insurance
A patient was seen in the physician office and paid a $10 copay on a $160 bill. The insurance company reimbursed the office for $100. In balance billing, what would happen? A.bill patient $50 B.write off $50 C.appeal $50 diff D.bill 2nd insurance $50 a
A group of physicians is reviewing if payment is adequate for services provided by a physician. This is referred to as a(n) A. carrier audit. B. peer review. C. appeal. D. ERISA. b
Dr. Jones is a nonPAR provider.Sent a claim to the insurance company for $200. The insurance companys allowable amt is $150. What happens to the remainin $50? A.should write it off B.should bill the patient C.should appeal the amt D.change the claim b
When an insurance company receives a claim form, which of the following is probably one of the first things to be checked? A. Patient’s insurance policy identification number B. Diagnosis and procedure codes C. Charges due D. Physician’s name a
A patient has a copay of $10, and the insurance company paid $90. Which of the following is the most likely allowed amount? A. $10 B. $90 C. $100 D. $80 c
The insurance company determined that a procedure wasn’t medically necessary and made adjustments to the claim. This is an example of A. manual review. B. claim denial. C. downcoding. D. a charge-based fee. c
If you want to see how much the patient may owe to the doctor, you should refer to the A. EOB service information section. B. COB service information section. C. EOB coverage determination. D. COB coverage determination. c
The 120 days to file for a Medicare appeals review is known as A. peer review. B. redetermination. C. administrative review. D. QIC. b
When a claim is submitted electronically, the explanation of benefits may be called a(n) A. EOB. B. ERA. C. COB. D. MCF b
A medical office has billed the insurance company for an excluded service with a charge of $150. What will happen? A. The insurance will reimburse the $150. B. The medical office will write off the $150 C.medical office will bill the patient $150 D.i c
Submitting additional information to an insurance company after a denial is called (a)n A. appeal. B. peer review. C. SOAP. D. QIC. a
A claim was pulled from the insurance company’s electronic system, and the medical office now needs to send additional information. What is this called? A. Capitation B. Write-offs C. Manual review D. Retention schedule c
The entity requesting a claim appeal is the A. claimant. B. adjudicator. C. PMPM. D. PAR. a
Dr. Jones is a PMPM provider. She gets $25 for each patient. There are 150 patients in the plan. What is her monthly reimbursement? A. $6 B. $25 C. $175 D. $3,750 d
Dr. Smith charged $150 for a procedure, but the insurance company’s allowed charges are $200. How much will the insurance reimburse the physician? A. $150 B. $200 C. $350 D. $50 a
Which of the following is used to control accounts receivable? A. Lockbox B. Conversion factor C. Write-offs D. Pending claim a
If a patient or insurance company overpays a physician and the medical office doesn’t refund the money in a timely manner, the physician could be charged with A. wrongful retention. B. remedies. C. preauthorization. D. redetermination. a
You just received an EOB and notice an error. What’s the first thing you should do A. Call the insurance company. B. Let the doctor know. C. Review the account information in the office. D. Write a letter to the patient. c
Having claims paid directly into the medical office bank account is called A. COB. B. EOB. C. EFT. D. ERA. c
Which of the followin is a reason a claim could be denied? A.submitted within 30 days of the office visit B.diagnosis code doesn’t reflect the procedure C.More than one procedure code was submitted D.coinsurance was deducted from the allowed charges B
A physician bases the fees for her service on what other physicians charge. She is using A. charge-based fees. B. resource-based fees. C. allowed charges. D. withholding. A
Which of the following helps determine the Medicare fee? A. RVU × CPT B. RBRVS × RVU C. UCR × RVU D. RVU × GPCI D
If no payment is due to the patient or the provider, what happens with the EOB? A. No EOB is needed. B. The EOB is sent to the physician. C. The EOB is sent to the patient. D. The EOB is sent to both the patient and the physician. D
Once an allowed charge has been set, A. physicians can appeal if they don’t agree. B. patients can appeal if they don’t agree. C. physicians are never paid more than that amount. D. physicians are never paid less than that amount. C
You need to write off the remaining balance for a patient’s account. This is called A. adjudication. B. adjustment. C. a charge-based fee. D. capitation. B
A patient has both primary and secondary insurance. Due to an office error, both insurances paid as primary. What should happen now? A.appeal process should be started B.patient should be notified C.money should be refunded D.patient should be billed C
u moved to a new state nd r workin for a physician. u need to know how long the office should keep patient records in this state. You should review the A.coordination of benefits B.retention schedule C.turnaround time D.geographic practice cost index B
With nationally uniform relative values, the practice expense is based on A. premiums. B. cost elements. C. overhead. D. geography. c
1. A physician offers money to other physicians to refer patients back to his practice. This is an example of A. underutilization. B. overutilization. C. kickbacks. D. internal fraud. c
2. An employee was injured on the job and was seen by the designated doctor. The next morning, the employee has another medical question. What should he do? A.Call the doc B.Call the medical office C.Call the workers comp office D.Call ombudsman c
3. Billing multiple procedure codes when one code would do is called A. self-referral fraud. B. upcoding. C. unbundling. D. creative billing fraud. c
4. Which of the following acts covers injuries for maritime workers? A. EEOICP B. LHWCA C. HIPAA D. FECA b
5. An employee needs help understanding evidence for dispute resolution proceedings. She should probably work with A. the physician. B. her employer. C. an ombudsman. D. a private attorney c
6. Billing for more expensive procedures than those actually performed is an example of A. self-referral fraud. B. upcoding. C. unbundling. D. creative billing fraud. b
7. An employee was injured by a machine at work and required an above-the-knee amputation of the right leg. Which of the following might he be eligible for? A.Temp income benefits B.Impairment income benefits C. Supplemental income D.Lifetime income d
An employee was injured and can no longer perform her old job duties. Which of the following state components will be beneficial to her? A.Max medical component B.Vocational rehab C.Impairment D.Notice of contest b
9. Which of the following is a federal program designed to help the elderly who have disabilities? A. SSN B. SSI C. FICA D. FECA b
10. Don was injured on his job with the Peace Corps. Which act provides workers’ compensation for Don? A. EEOICP B. LHWCA C. HIPAA D. FECA d
11. An employer has denied an employee’s worker compensation claim. What should happen next? A.file a state claim. B.file a federal claim. C.provide the employee w/ a Notice of Consent D.provide the employee w/ an Admission of Liability c
Which of the followin might not receive death benefits from an employee killed at work? A.Spouse still married B.Minor child still livin at home C.Cousin who relied on deceased to pay her bills D.Ex-wife who received 5% of her income in alimony d
An employee was injured 8 days ago on the job and will be able to go back in 7 more days. The employee may be eligible for? A.Temp income benefits B.Impairment income benefits C.Supplemental income benefits D.Lifetime income benefits a
Which of the following would probably be considered a compensable injury? A.breaks her arm after having drinks co-workers B.breaks his arm durin football @ the company picnic C.struck by lightnin carryin trash outside D.hurts his back liftin boxes d
15. If an employee dies because of a work-related injury, what happens to the benefits? A. They’re paid to the employee’s family. B. They’re retained by the employer. C. They’re paid into the state fund. D. They’re paid into the federal fund. a
15. Which of the following makes sure that federal workers are covered if injured on the job? A. HIPAA B. AMA C. OWCP D. IRO c
If an employer is providin an Admission of Liability, it is A.denyin workers comp claim B.acknowledgin workers comp claim C.gettin reimbursed for an employee’s workers compensation claim D.reimbursin 4 an employee’s workers’ compensation claim b
17. Which of the following covers lost wages? A. Disability compensation B. Medical compensation C. FECA D. OSHA a
18. Which of the following provides a final administrative review of the appropriateness and medical necessity for a patient? A. URA B. HMO C. IRO D. FECA c
19. Carpal tunnel syndrome is an example of a(n) A. nontraumatic illness. B. noncompensable injury. C. act of God. D. impairment. a
20. An employer uses a state workers’ compensation fund. Employer premiums are paid A. into the state fund. B. into the federal fund. C. to the employee. D. to the employer. a
21. Which of the following employers would not be regulated by OSHA? A. St. Mary’s Church B. ABC Trucking C. Smith’s Grocery Store D. Triple Gas Station a
22. When a doctor is receiving a fixed fee for treating a patient but providing inadequate treatment, it could be viewed as A. underutilization. B. overutilization. C. a kickback. D. internal fraud. a
Betty received a 3rd degre burn on the job and couldn’t return to work for 4 weeks. Which classification would Betty probably fall under? A.Injury without disability B.Injury w/ temp disability C.Injury w/ permanent disability D.Injury requirin rehab b
Which of the followin are tryin to comit workers comp fraud? A.arm in a cast& says she fell last Thursday B.she felt a pain in her back after liftin boxes C.burned her hand on the coffee pot D.needs to be treated for carpal tunnel cuz of amt of typin a
25. An employee has a permanent injury from work with a 5% rating. Which of the following may he be eligible for? A. Temporary income benefits B. Impairment income benefits C. Supplemental income benefits D. Lifetime income benefits b
1. A printed record of the patient’s visit to the hospital is known as a A. walkout receipt. B. patient day sheet. C. total adjustment. D. total receipt. a
Money received for services provided by physicians is known as A. postings. B. charges. C. payments. D. transactions. c
If you wanted to compare all the totals for the day, where would you look? A. Walkout receipt B. Patient day sheet C. Adjustments D. Receipts b
Dan has a job in a medical office where he enters what the physician charges for each service provided to the patient into the billing system. Dan is working with A. postings. B. charges. C. payments. D. transactions. b
Most offices now keep patient information and transactions via A. manual bookkeeping. B. the Internet. C. medical records. D. medical practice management software. d
Part of your work responsibility is entering dollar amounts into the computer. You are probably working on A. posting. B. charges. C. payments. D. transactions. a
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