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Final Exam Review
HIT 130 Final Exam Review
| Question | Answer |
|---|---|
| If a patient has health insurance coverage with more than one medical insurance plan, the medical assistant bills the secondary insurance ________ the primary insurance. | after payment has been made by |
| The ________ claim form must be used to submit paper claims to Medicare for a physician's services. | CMS-1500 |
| The Advance Beneficiary Notice (ABN) must be signed by patients before they can receive covered services that may be denied payment by ________. | Medicare |
| Which is the most restrictive type of healthcare plan? | HMO |
| What is NOT considered an out-of-pocket expense? | Fee for service |
| The ________ is a unique, ten-digit number assigned to healthcare providers by the CMS. | national provider identifier (NPI) |
| Which TRICARE insurance plan is a fee-for-service plan? | Standard |
| When employees have been covered under group insurance and leave employment, they may have the opportunity to continue the group coverage at their own expense under a ________ policy. | COBRA |
| What is NOT true about the CMS-1500 form? | used for electronic claims |
| True or false? "Days in AR" means the average number of days that money has been owed to the patient. | False |
| True or false? Mutual understanding of financial arrangements helps to minimize problems of collection for delinquent accounts. | True |
| The RA/EOB lists all the following EXCEPT ________. | the amount past due |
| Insurance ________ codes are used on the EOB to explain payment adjustments and denials. | reason |
| An internal audit would determine: | the coders' skill and knowledge, whether procedures were coded correctly, if additional training is needed for office staff. |
| An independent audit should be performed a minimum of: | twice a year. |
| True or false? A retrospective audit is conducted before sending claims to an insurance company. | False |
| If a patient wishes insurance payments to be made directly to the provider, the patient must sign which type of form? | Assignment of benefits form |
| A child is covered by insurance plans from both parents. The mother's birthday is 10/15/1986 and the father's birthday is 12/15/1985. Based upon the birthday rule, which insurance is primary? | Mother |
| The category of workers' compensation benefits that will pay for medical expenses only is injury: | without disability. |
| What is a timely filing requirement? | The time frame a provider has to submit a claim. |
| What is NOT a benefit of becoming a participating provider for Medicare? | A participating provider may charge up to 115 percent of the approved amount |
| Medicare Advantage plans fall under which part of Medicare? | Part C |
| What is a service that would be expected to be reported on a CMS-1500 claim form? | Physician office visits and surgical procedures |
| What does it mean for a provider to accept assignment? | To accept the negotiated rate as the full rate for the service |
| What type of services are reported on a UB-04 form? | Hospital facility services |
| Which form is used to indicate the services performed and the diagnosis for a visit? | Encounter form |
| Which form should be completed to determine if Medicare is a primary or secondary insurance? | MSP |
| Which term refers to guarding against improper information modification or destruction? | Security |
| An individual's right to control access to his or her personal information is known as: | Privacy |
| Social Security Disability Insurance (SSDI) is paid for by: | workers' payroll deductions matched by employer contributions. |
| Medical benefits for an injured worker begin: | immediately and have no specific time limit. |
| A _____________ is correspondence sent from the insurance payer to the patient after they receive healthcare services to explain the status of a claim. | Explanation of Benefits |
| What does a participating provider agree to when signing a contract with an insurance payer? | The provider wishes to participate with and agree to accept the fee schedules set by that specific insurance. |
| Which type of insurance allows members to choose medical services as needed and can go in or out of network? | POS |
| Which is a reimbursement plan that is funded by employers? | HRA |
| Workers' Compensation insurance payers and the state compensation boards/commissions are entitled by law to review: | Only treatment data and history pertaining to the patient's on-the-job injury |
| Which injuries qualify for workers' compensation? | Injured while working within the scope of their job description, Injured while performing services required by the employer, Contract an illness that can be directly connected to employment |
| What is the time limit for filing the first injury of report form? | Will vary by state |
| The entity that provides workers' compensation insurance coverage to private and public employers and acts as an agent in state workers' compensation cases involving state employees is the: | State Insurance Fund |
| Which federal program provides compensation and medical coverage to coal miners disabled by pneumoconiosis? | Federal Black Lung Program |
| Who is responsible to pay the premiums for workers' compensation insurance? | Employer |
| Claims processing involves the verification of medical necessity for the reported procedures; this task is performed by: | medical review examiners. |
| When a claim has been down coded or denied by the insurance carrier, the medical office specialist can ask for reconsideration by filing: | an appeal |
| The state official who has regulatory control over insurance carriers and can assist with disputes is the: | state insurance commissioner. |
| No matter what amount a provider charges for a given service, each third-party payer will establish the amount they will pay based on what is considered: | usual, customary and reasonable |
| The RBRVS system establishes the nationally uniform relative value of a service based on which three cost elements? | The physician's work, the practice expense, and the cost of liability insurance |
| In regard to the RBRVS system, the time it takes to perform a service is considered to be part of the: | provider's work |
| In regard to the RBRVS system, the risk of harm posed to the patient by a particular service or procedure is considered to be part of the: | cost of liability insurance |
| The deductible under most insurance plans applies to each covered individual each: | calendar year |
| True or false? A. patient's out-of-pocket expenses include deductibles, coinsurance and copayments. | True |
| What is a Medigap policy? | A policy that covers healthcare services that Medicare does not cover. |
| Medicare Part A is available to individuals under the age of 65 who have: | ESRD ( End Stage Renal Disease) and meet certain requirements |
| Which of the following statements is true regarding Medicaid? | Medicaid programs receive matching federal funding only if certain healthcare services are provided to eligible individuals. |
| By signing the Assignment of Benefits in item 13 of the CMS-1500 claim form, the patient is: | Directing the insurance company to send the reimbursement to the provider. |
| The Health Insurance Portability and Accountability Act defines abuse as: | Actions not consistent with accepted and sound medical, business, or fiscal practices. |
| A claim has been processed by the payer, payment received and posted to the patient's account. What is the next step in the billing process? | A statement is sent notifying the patient of their remaining responsibility. |
| When an account has been determined (by the practice's policy) to be delinquent, the account should: | Be turned over to a collection agency |
| To manage patient accounts effectively, claims should be tracked for: | Coding errors and overpayments |
| The purpose of GPCI is to account for: | regional differences in costs |
| The Medicare conversion factor is set: | once each year |
| Some insurance carriers perceive automatic rebilling after 30 days to be aggressive and a: | fraudulent practice |
| ERISA stands for the: | Employee Retirement Income Security Act. |
| When a provider receives a partial payment on a claim because the amount billed was in excess of the maximum allowed charge, this is a: | disallowance |
| Wrongfully keeping an overpayment is illegal and is called: | conversion |
| The steps that result in an insurance carrier's decision to either pay or deny a claim is known as: | adjudication. |
| When a claim has been down coded or denied by the insurance carrier, the medical office specialist can ask for reconsideration by filing: | an appeal |
| Write-off | Billed Charge - Allowed Amount= |
| Patient Responsibility | Allowed Amount x Coinsurance Rate= |
Created by:
Prof Clark