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CHAPTER 5,15,6,7,8.9


A major innovation that made the process of health insurance claims submission simpler was the development of? A universal form
The front side of the CS-1500 claim form is printed in? OCR scannable RED ink
The most common FORMAT used for TEXT FILES in computers and on the internet is? ASCII
OCR formatting rules specify? All entries in uppercase; NO punctuation; MM/DD/YYYY birth date format
A "SMALL PROVIDER" of services is one with less than? 25 full-time equivalent employees
The patient inforation form is considered a legal document and should be updated no less than? Once a year
A patients name, address, Social Security number and employment data are commonly referred to as? Demographic information
An individual covered under Medicare is referred to as a(an)? Beneficiary
An insurance policy that covers an individual, his or her spouse, and eligible dependents is referred to as a(an)? Family plan
A multipurpose form used by most practices for billing is called a(an)? Superbill; encounter form or routing form
In noncomputerized practices, patient charges and payments can be tracked manually on a(an)? Patient ledger card
How many blocks does the CMS-1500 claim form have? 33
After the health insurance professional has completed the claim form, it should be? Proofread
An example of a method for manual claims follow-up is using an? Insurance log and Insurance register
A company that recieves claims, consolidates them, and transmits the in batches to third-party payers is called a? Clearinghouse
OCR is? Optical character recognition
What are the 2 major sections of the CMS-1500 claim form? Top portion is for the patient, bottom portion is for the physician.
When the health insurance professional hs completed the claim form, it is crucial that the form is thoroughly examined for? Errors and omissions
What is the health insurance professional's MOST important task? To obtain the maximum amount of reimbursment in the minimum amount of time that the medical record supports.
Who uses the paper CMS-1500 form? Providers who are not computerized & unable to transmit electronically and SMALL providers with less than 25 full time employees or less than 10 in a doctor's office
ASCA prohibits HHS from paying Medicare claims that are NOT submitted electronically, unless the secretary grants a(an)? Waiver
Define a "SMALL PROVIDER". Has less than 25 full time employees or lessthan 10 in a doctor's office.
What are 3 reasons healthcare facilities use patient information form. To gather all necessary demographic informationTo have a record of current insurance info for claims,To keep health records up-to-date.
What is the signifigance of a patient "ASSIGNING BENEFITS"? Authorizes insurance company to send payment directly to helthcare professional.
The type of insurance that comprises a group of providers who share the fincial risk of the plan or who have an incentive to deliver cost-effective, but quality service is a(an)? Managed care plan
The amount of money the policyholder has to pay out-of-pocket for any one incident or in any 1 year is limited by? Insurance cap
The government health insurance program that provided coverage for it's own civilian employee's is called? Federal Employees Health Benefits Program (FEHB)
The federal law designed to protect the rights of beneficiaries of employee benefit plans offered by employers and that sets minimum standards for pension plans in private industry is called? Employee Retirement Income Security Act (ERISA)
A person or organization that processes claims and performs othe contractual administrative services is commonly referred to as? Third Party Administrator (TPA)
Name 4 basic types of insurance plans Traditional FFS/Indemnity plans, Preferred Provider Organizations(PPO's), Point Of Service Plans (POS), Health Maintennce Organizations (HMO's)
What are 3 out-of-pocket costs that are standard for patients to pay with FFS plans? Premium; Deductible; Cost Sharing/Coinsurance
What is a "CARVE OUT"? Eliminating a certain specialty of health services fromm coverage undef the healthcare policy. (ex..Mental Health)
What is meant by "TIMELY FILING" relating to claims? Filing claims within time alotted will avoid claims being denied.
Timely filing for Blue Cross and Blue Shield claims is? 4 Month's (120 days)
Created by: Jeannie-Snyder