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MED112 CODE/BILL
MED112 CH 07 HEALTHCARE CLAIM PREPARATION AND TRANSMISSION SB
| Question | Answer |
|---|---|
| MED112 CH 07 SB | |
| The current paper claim approved by the NUCC is called the ____ claim form. A. CMS-1500 B. PMP-1500 C. NC-10 D. HIPAA-837 | A. CMS-1500 |
| What committee is responsible for modifying the instructions for the CMS-1500 to bring it in more accord with the electronic claim without having to change the overall layout? A. NICU B. NUCC C. CMS D. AMA | B. NUCC |
| The CMS-1500 claim has a carrier block and how many Item Numbers (INs)? A. Thirty-four B. Thirty-three C. Thirty-one D. Thirty-two | B. Thirty-three |
| The electronic HIPAA claim is based on the ____ which is a paper claim form. A. HCFA-1500 B. CMS-1500 C. HIPAA-1500 D. CMA-1500 | B. CMS-1500 |
| In the carrier block of the CMS-1500 form, commas, periods, and other punctuation marks, are ____ used in the address. A. sometimes B. always C. never D. rarely | C. never |
| HIPAA requires electronic transmission of claims except for practices that have fewer than ____ full-time or equivalent employees and never send any kind of electronic healthcare transactions. A. ten B. twenty-five C. twenty D. fifteen | A. ten |
| The items in the ____ information section of the CMS-1500 form identify the patient, the insured, and the health plan. A. insurance B. patient C. guarantor D. health plan | B. patient |
| The organization responsible for claim content is abbreviated as A. AHIMA B. HIPAANCC C. CMS D. NUCC | D. NUCC |
| The Item Number for EPSDT Family Plan refers to some services that may be covered under state ____ plans. A. Medicaid B. Medicare C. private payer D. TRICARE | A. Medicaid |
| Where is the carrier block located on the CMS-1500? A. Lower left portion B. Loewr right portion C. Upper left portion D. Upper right portion | D. Upper right portion |
| What code is a ten-digit number that stands for a physician's medical specialty? A. Taxonomy B. ICD C. CPT D. Place of Service | A. Taxonomy |
| The ____ provider is a provider of health services reported on a claim, usually a physician practice. A. billing B. rendering C. participating D. pay-to | A. billing |
| The organization of the data elements on the ____ is efficient for electronic transmission rather than for use on a paper form. A. Medicaid Claim B. HIPAA 837P Claim C. CMS-1500 Claim D. ICD-10-CM | B. HIPAA 837P Claim |
| What term is used on the HIPAA 837P for the insurance policyholder or guarantor, meaning the same thing as the insured on the CMS-1500 claim? A. prescriber B. subscriber C. guardian D. insured | B. subscriber |
| What kind of vendors are responsible for keeping their software products up to date? A. PMP B. POS C. CPT D. NPI | A. PMP |
| What number, unique for each claim, is assigned by the sender? A. Provider identification B. Patient identification C. Claim identifier D. Claim control | D. Claim control |
| The ______ may affect the physician’s pay, usually because of the payer’s contract with the physician. A. provider’s gender B. length of time the provider has been licensed C. type of specialty D. diagnosis code | C. type of specialty |
| The payer information section of the HIPAA 837P claim contains information about the payer to whom the claim is going to be sent, called the ______. A. insurance payer B. subscriber C. guarantor D. destination payer | D. destination payer |
| The HIPAA 837P claim contains many ______ that are essentially the same as those used to complete a CMS-1500; they are just organized in a different way. A. diagnosis codes B. item characters C. data elements D. procedure codes | C. data elements |
| Most ____ provide a way for the medical insurance specialist to review claims for accuracy and to create a record of claims that are about to be sent. A. NPIs B. CPTs C. PMPs D. PIPs | C. PMPs |
| What are claims called that are accepted for adjudication by payers? A. Clean claims B. Replacement claims C. Voided claims D. Original claims | A. Clean claims |
| What is the maximum number of characters used for the claim control number? A. Seven B. Twenty C. Nine D. Ten | B. Twenty |
| When entering telephone numbers on claims, what should not be used? A. dashes B. parenthesis C. numbers D. spaces | A. dashes B. parenthesis D. spaces |
| How many diagnosis codes can be linked to each service line procedure? A. two B. eight C. four D. one | C. four |
| The data elements that are transmitted electronically are not seen physically as they would be on a ____ form. A. data entry B. referral C. computer D. paper | D. paper |
| A ____ is additional data in printed or electronic format sent to support a claim. A. diagnosis code pointer B. service line attachment C. claim note D. claim attachment | D. claim attachment |
| What is an important step to perform before claim transmittal? A. Scan the claim B. Check the claim C. File the claim D. Evaluate diagnosis codes | B. Check the claim |
| For each ______, an NPI number and possibly non-NPI numbers with the qualifiers must be reported on the HIPAA 837P claim. A. place of service B. provider C. procedure code D. patient | B. provider |
| Codes two, three, and four of the diagnosis code pointers may also be linked, in ______ level of importance regarding the patient’s treatment, to the service line. A. increasing B. lower C. highest D. declining | D. declining |
| Health plans can require providers to submit claim attachments in which of the following formats? A. Available on request at provider site B. By email C. By fax D. By telephone E. By mail | A. Available on request at provider site B. By email C. By fax E. By mail |
| If applicable, who is reported as the entity or person other than the subscriber or patient who has financial responsibility for the bill? A. Dependent B. Subscriber C. Policyholder D. Responsible party | D. Responsible party |
| To transmit claims directly what must a provider supply? A. content of each IN or data element B. telephone lines to transmit C. clearinghouse standards D. HIPAA data elements | D. HIPAA data elements |
| Which of the following are among the most common errors on claims? A. Missing or invalid patient birth date B. Using valid procedure codes C. Missing part of the name or the identifier of the referring provider D. Patient’s marital status missing on claim | A. Missing or invalid patient birth date C. Missing part of the name or the identifier of the referring provider |
| What are editing software programs called that make sure that all required fields are filled and only valid codes are used, and perform other checks? A. Claim scrubbers B. Clearinghouses C. Clean claims D. Direct data | A. Claim scrubbers |
| What involves using an internet-based service into which employees key the standard data elements? A. DDI B. DDE C. NPI D. POS | B. DDE |
| What are some data entry tips for submission of clean claims? A. Do not use prefixes for people’s names B. Do not check with payers for exceptions to the guidelines C. Only enter numbers in the ZIP code field D. Do not use special characters unless required by the carrier | A. Do not use prefixes for people’s names C. Only enter numbers in the ZIP code field D. Do not use special characters unless required by the carrier |
| Some payers offer online ______ to providers, which involves using an Internet-based service into which employees key the standard data elements. A. claim attachments B. clearinghouses C. direct data entry D. service line entry | C. direct data entry |
| What are prepared for transmission after all required data elements have been posted to the practice management program? A. Codes B. Claims C. Procedures D. Clearinghouses | B. Claims |
| What kind of technology is required for a provider to submit claims directly? A. Microsoft Windows B. Excel C. special D. Word | C. special |
| The majority of providers use ______ to send and receive data in correct EDI format. A. third-party payers B. outside billers C. clearinghouses D. insurance companies | C. clearinghouses |
| To transmit claims directly what must a provider supply? A. HIPAA data elements B. clearinghouse standards C. content of each IN or data element D. telephone lines to transmit | A. HIPAA data elements |
| The NPI is used to report the ________ on a claim. A. provider identifier B. patient identifier C. payer identifier D. employer identifier | A. provider identifier |
| On HIPAA claims, a required data element ________. A. is optional. B. must be supplied. C. is entered in capital letters. D. must be entered in italics. | B. must be supplied. |
| The HIPAA X12 276/277 Health Care Claim Status Inquiry/Response transaction is used to ________. A. transmit claims. B. transmit claim attachments. C. ask about the status of claims that have been transmitted. D. transmit paper claims. | C. ask about the status of claims that have been transmitted. |
| The content of claims and the healthcare provider taxonomy codes are set by ________. A. HIPAA B. NUCC C. ICD-10-CM D. CPT/HCPCS | B. NUCC |
| The number of the HIPAA Professional claim transaction is A. CMS-1500 B. HCFA-1500 C. X12 837P D. X12 834 | C. X12 837P |
| If a physician practice sends claims directly to a payer and receives payments directly, which of these entities does not need to be additionally reported? A. referring provider B. rendering provider C. billing provider D. pay-to provider | D. pay-to provider |
| The POS code for a military treatment facility is A. 12 B. 26 C. 42 D. 72 | B. 26 |
| Which of the following may be the same person as the patient? A. referring provider B. subscriber C. pay-to provider D. destination payer | B. subscriber |
| Organize the elements of the claim hierarchy in the correct order, from highest to lowest. -Provider -Claim details -Payer -Subscriber and patient -Services | 1. Provider 2. Subscriber and patient 3. Payer 4. Claim details 5. Services |
| Which of the following is not a commonly used transmission method for HIPAA claims? A. fax B. direct data entry C. direct transmission D. clearinghouse | A. fax |
| CMS 1500 Claim Form box Carrier Block | Payer name and address |
| CMS 1500 Claim Form box Patient Information | Insurer’s ID number |
| CMS 1500 Claim Form box Insurance Plan Name | Aetna PPO, for example |
| CMS 1500 Claim Form box Claim Codes | Condition codes |
| CMS 1500 Claim Form box FECA Number | Nine-digit alphanumeric identifier assigned to a patient who is an employee of the federal government claiming work-related condition(s) |
| CMS 1500 Claim Form box DN | Qualifier for referring provider |
| CMS 1500 Claim Form box Rendering provider | Professional providing health care services on the claim |
| CMS 1500 Claim Form box 1G | Provider UPIN number |
| CMS 1500 Claim Form box ICD Indicator “0” | ICD-10 codes utilized |
| CMS 1500 Claim Form box Resubmission code “8” | Void prior claim |
| CMS 1500 Claim Form box POS code | Facility type code |
| CMS 1500 Claim Form box Place of Service code “31” | Skilled nursing facility |
| CMS 1500 Claim Form box Federal Tax ID number | Employer Identification Number |
| Entity that is sending the claim to the payer | Billing provider |
| Claim accepted by a health plan for adjudication | Clean claim |
| Insurance carrier that is to receive the claim | Destination payer |
| Unique number assigned by the sender to each service line on a claim | Line item control number |
| Entity that is to receive payment for the claim | Pay-to provider |
| Stands for the type of facility in which services reported on the claim were provided | POS code |
| Software used to check claims | Claim scrubber |
| Provider of healthcare services reported on a claim | Rendering provider |
| The insurance policyholder or guarantor for the claim | Subscriber |
| Stands for the type of provider specialty | Healthcare Provider Taxonomy Code (HPTC) |
| The data entry area in the upper right portion of the CMS-1500 | Carrier block |
| Paper claim for physician services | CMS-1500 |
| Which Item Numbers on the CMS-1500 claim form contain information about the provider and the patients condition, including the diagnoses, procedures, and charges? A. Item Numbers 14-33 B. Item Numbers 1-33 C. Item Numbers 14-31 D. Item Numbers 1-13 | A. Item Numbers 14-33 |
| Which of the following pieces of information are included in the patient information section of the CMS-1500 claim form? (MAY BE MORE THAN ONE) A. Insured’s information B. Code linkage C. Health plan’s information D. Procedure information E. Patient information | A. Insured’s information C. Health plan’s information E. Patient information |
| Which of the following items are identified in the Physician/Supplier part of the CMS-1500 claim form? (MAY BE MORE THAN ONE) A. Patient insurance number B. Services performed C. Healthcare provider D. Insurance information E. Additional information to process the claim | B. Services performed C. Healthcare provider E. Additional information to process the claim |
| What number, unique for each claim, is assigned by the sender? A. Patient identification B. Claim control C. Claim identifier D. Provider identification | B. Claim control |
| The ________ is the person or organization that receives payment for the claim. A. health plan B. rendering provider C. pay-to provider D. participating provider | C. pay-to provider |
| Which of the following items are identified in the Physician/ Supplier part of the CMS-1500 claim form? (MAY BE MORE THAN ONE) A. Healthcare provider B. Services performed C. Patient insurance number D. Additional information to process the claim E. Insurance information | A. Healthcare provider B. Services performed D. Additional information to process the claim |
| What are some data entry tips for submission of clean claims? (MAY BE MORE THAN ONE) A. Do not use prefixes for people’s names B. Only enter numbers in the ZIP code field C. Do not use special characters unless required by the carrier D. Do not check with payers for exceptions to the guidelines | A. Do not use prefixes for people’s names B. Only enter numbers in the ZIP code field C. Do not use special characters unless required by the carrier |
| The ________ provider is a physician or other entity, such as a lab, that has provided the care. A. rendering B. billing C. participating D. pay-to | A. rendering |
| Which part of the CMS-1500 claim form identifies the healthcare provider, describes the services performed, and gives the payer additional information to process the claim? A. Patient’s information section B. Physician/supplier information section C. Insured’s information section D. Insurance company information section | B. Physician/supplier information section |
| The HIPAA-mandated electronic transaction for claims from physicians and other medical professionals is the ________ Health Care Claim: Professional. A. HIPAA X13 838 B. HIPAA X12 838 C. HIPAA X12 837 D. HIPAA X13 837 | C. HIPAA X12 837 |
| For many years, the CMS-1500 was the universal physician health claim accepted by most payers, which was a red and black printed form that was typed or computer-generated and mailed to ________. A. payers B. the insured C. payees D. healthcare practices | A. payers |
| Under HIPAA EDI transactions must move to which format for 837P claims to provide enough room for ICD-10-CM codes and for additional data? A. 1500 version B. 5010A1 version C. CMS-1500 D. HCFA-1500 | B. 5010A1 version |
| In the carrier block of the CMS-1500 form, commas, periods, and other punctuation marks are ________ used in the address. A. always B. never C. rarely D. sometimes | B. never |
| PMP vendors are responsible for which of the following? (MAY BE MORE THAN ONE) A. Processing CMS-1500 claims for submission and claim tracking B. Receiving certification from HIPAA testing vendors that their software can accommodate HIPAA-mandated transactions C. Training office personnel in the use of new features D. Keeping their software products up to date | B. Receiving certification from HIPAA testing vendors that their software can accommodate HIPAA-mandated transactions C. Training office personnel in the use of new features D. Keeping their software products up to date |
| Like the CMS-1500, the HIPAA 837P claim requires data on which of the following types of providers? (MAY BE MORE THAN ONE) A. Referring provider B. Pay-to provider C. Rendering provider D. Participating provider E. Billing provider | A. Referring provider B. Pay-to provider C. Rendering provider E. Billing provider |
| What does EPSDT stand for? A. Early and periodic screening, diagnosis, and treatment B. Early and periodic screening, diagnosis, and testing C. Early post-screening, diagnostic treatment D. Educated periodic screening, diagnosis, and testing | A. Early and periodic screening, diagnosis, and treatment |
| Some payers offer online ________ to providers, which involves using an Internet-based service into which employees key the standard data elements. A. clearinghouses B. service line entry C. direct data entry D. claim attachments | C. direct data entry |
| At least ________ diagnosis code must be linked to the procedure code. A. four B. three C. one D. two | C. one |
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