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MED112 CODE/BILL
MED112 CH 13 PAYMENTS (RAs), APPEALS, & SECONDARY CLAIMS SB
| Question | Answer |
|---|---|
| MED112 CH 13 SB | |
| Adjudication Process - place the steps in order -Determination -Initial processing -Payment -Manual review -Automated review | 1. Initial processing 2. Automated review 3. Manual review 4. Determination 5. Payment |
| HIPAA 277 Claim Status Category Codes: A = ACKNOWLEDGEMENT of receipt P = PENDING F = FINALIZED R = REQUEST more information E - ERROR | A - Acknowledgement the claim has been received. P - Payer is waiting for information before deciding. F - Claim has been finalized. R - Request for more information has been sent. E - Error occurred; claims usually need to be resent. |
| What summarizes the results of the payer's adjudication process? A. PMP B. EOB C. RA D. PCP | C. RA |
| What should the medical insurance specialist do when the payer rejects claims with errors or simple mistakes and transmits instructions to the provider to correct errors and/or omissions and to rebill the service? (MAY BE MORE THAN ONE) A. Call the insurance company and give the correct information. B. Wait for the insurance company to correct the information before rebilling. C. Respond ASAP by supplying the correct information. D. Submit a clean claim, that the payer accepts for processing. | C. Respond as quickly as possible by supplying the correct information. D. Submit a clean claim, if necessary, that the payer accepts for processing. |
| Which of the following questions are typically asked when performing the automated review check to determine patient eligibility for benefits? (MAY BE MORE THAN ONE) A. Is the patient eligible for the services that are billed? B. Has the claim been sent within the payer's time limits for filing claims? C. Does the patient have any dependents? D. Are valid preauthorization or referral numbers present as required under the payer's policies? | A. Is the patient eligible for the services that are billed? B. Has the claim been sent within the payer's time limits for filing claims? D. Are valid preauthorization or referral numbers present as required under the payer's policies? |
| When claims are sent to the medical review department to be reviewed by a claims examiner, the examiner may ask the provider for clinical documentation to check which of the following? (MAY BE MORE THAN ONE) A. Whether the treatments were appropriate and a logical outcome of the facts and conditions shown in the medical record B. Whether patient payments are up-to-date C. Whether 3+ modifiers have been added to CPT. D. Where the service took place E. Whether services provided were accurately reported | A. Whether the treatments were appropriate and a logical outcome of the facts and conditions shown in the medical record D. Where the service took place E. Whether services provided were accurately reported |
| For each service line on a claim, the payer makes a payment determination to decide on which of the following? (MAY BE MORE THAN ONE) A. Deny the claim B. Pay the claim C. Pay the claim at a reduced level D. Pay the claim at a higher level | A. Deny the claim B. Pay the claim C. Pay the claim at a reduced level |
| When the payer receives claims, what kind of response is issued to the sender showing that the transmission has been successful? A. Mail B. Paper C. Email D. Electronic | D. Electronic |
| The HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835) is the HIPAA-mandated electronic transaction for payment explanation. What is the document that the beneficiary receives? A. EOB B. RA C. ERA D. PCP | A. EOB |
| Which of the following problems might be found in the initial processing of a claim? (MAY BE MORE THAN ONE) A. The diagnosis code is missing or is not valid for the date of service. B. The patient's name, plan identification number, or place of service code is wrong. C. The patient is not the correct sex for a reported gender-specific procedure code. D. There is more than one diagnosis code for the procedure and the date of service. | A. The diagnosis code is missing or is not valid for the date of service. B. The patient's name, plan identification number, or place of service code is wrong. C. The patient is not the correct sex for a reported gender-specific procedure code. |
| The accounts receivable is made up of payments from which of the following? (MAY BE MORE THAN ONE) A. Money due from payers B. Money due from patients C. Money due from the doctor D. Money due from vendors | A. Money due from payers B. Money due from patients |
| What phrase refers to medical attention when the patient receives extensive care from two or more providers on the same date of service? A. Medical care B. Primary care C. Secondary care D. Concurrent care | D. Concurrent care |
| What is the time period in which a health plan must process a claim? A. Claim turnaround time B. Prompt turnaround time C. Prompt pay time D. Claim processing time | A. Claim turnaround time |
| If problems are identified in the automated review, what two things will happen to the claim? (MAY BE MORE THAN ONE) A. The claim will be suspended. B. The claim will be paid. C. The claim will be set aside for development. D. The claim will be accepted. | A. The claim will be suspended. C. The claim will be set aside for development. |
| A(n) ______ denial may result from a lack of clear, correct linkage between the diagnosis and procedure. A. Bundled code B. Utilization review C. Medical necessity D. Noncovered service | C. Medical necessity |
| To have claims processed as quickly as possible, medical insurance specialists must be familiar with which of the following payers' claim-processing procedures? (MAY BE MORE THAN ONE) A. Timetables for submitting corrected claims and for filing secondary claims B. How to handle requests for additional documentation if required by the payer C. How to submit claims that are delayed for missing or incorrect data D. How to resubmit corrected claims that are denied because of missing or incorrect data | A. Timetables for submitting corrected claims and for filing secondary claims B. How to handle requests for additional documentation if required by the payer D. How to resubmit corrected claims that are denied because of missing or incorrect data |
| When a payment is due for an approved claim, the payer sends which of the following to the provider along with the payment? A. Explanation of benefits B. Electronic remittance transmission C. Remittance advice D. Electronic EOB | C. Remittance advice |
| Whether sent electronically or in a paper format, the basic information in the remittance advice transaction is ______. A. the same B. similar C. different D. not the same | A. the same |
| What do practices use to closely track the money that is owed for services rendered? A. Newspaper reports B. Practice management program C. Electronic health records D. Prompt payment laws | B. Practice management program |
| What laws obligate state-licensed carriers to pay clean claims for both participating and nonparticipating providers within a certain time period or incur interest penalties, fines, and lawyers' fees? A. Prompt-pay laws B. Prompt processing laws C. Claim turnaround laws D. Claim payment laws | A. Prompt-pay laws |
| Which of the following types of information are often located in separate sections on an RA? (MAY BE MORE THAN ONE) A. Header information B. Claim information C. Totals D. Recipient information E. Glossary | A. Header information B. Claim information C. Totals E. Glossary |
| What is the standard electronic transaction that obtains information on the current status of a claim during the adjudication process? A. HIPAA X12 277 Health Care Claim Status Inquiry B. HIPAA X12 276 Health Care Claim Status Response C. HIPAA 276/277 Health Care Claim Status Inquiry/Response D. HIPAA X12 276/277 Health Care Claim Status Inquiry/Response | D. HIPAA X12 276/277 Health Care Claim Status Inquiry/Response |
| Which of the following is not an example of a payment adjustment on the RA? A. Zero payment due to no reimbursement B. Reduced amount paid based on the allowed amount C. Denial of the claim D. Full payment as billed | D. Full payment as billed |
| When do some payers use online or automated telephone procedures or special forms to resubmit claims? A. To follow up before a claim has been resubmitted B. Before missing information has been supplied C. After missing information has been supplied D. To follow up after a claim has been resubmitted | C. After missing information has been supplied |
| Regulations mandated under the ______ as of January 1, 2014, require a trace number to appear on both the EFT and its ERA, so the documents are easy to match electronically. A. Medicare Act B. Centers for Affordable Care Act C. Affordable Care Act D. Payment Care Act | C. Affordable Care Act |
| Which of the following are examples of payment and adjustment transactions that are entered in the practice management program? (MAY BE MORE THAN ONE) A. Payer name and type B. Check or EFT number C. Total payment amount D. Date of check E. Date of deposit | A. Payer name and type B. Check or EFT number C. Total payment amount E. Date of deposit |
| A(n) ______ lists claims that have been adjudicated within the payment cycle alphanumerically by the patient account number assigned by provider, alphabetically by client name, or numerically by the internal control number. A. PMP B. EOB C. RA D. CPT | C. RA |
| The process of ______ means making sure that the totals on the RA check out mathematically. A. Reconciliation B. Auditing C. Appeals D. Autoposting | A. Reconciliation |
| Which of the following explains Medicare payment decisions? A. Medicare adjustment codes B. Claim adjustment reason codes C. MOA remark codes D. Claim adjustment group codes | C. MOA remark codes |
| If a claim is denied or downcoded for lack of medical necessity, which of the following would be the next actions to take? (MAY BE MORE THAN ONE) A. Challenge the determination with an appeal. B. Bill the patient. C. Write off the amount as a contractual adjustment. D. Bill the insurance company. | A. Challenge the determination with an appeal. B. Bill the patient. C. Write off the amount as a contractual adjustment. |
| To process the RA, the remittance data are reviewed and then posted where? A. CPT B. PCP C. EOB D. PMP | D. PMP |
| When a claim has been denied or payment reduced, an ______ may be filed with the payer for reconsideration, possibly reversing the nonpayment. A. Audit B. Adjustment C. Appeal D. Explanation | C. Appeal |
| Many practices that receive RAs authorize the payer to deposit directly into the practice's bank account through a(n) ______. A. PMP B. EFT C. EOB D. CPT | B. EFT |
| A(n) ______ is a process that can be used to challenge a payer's decision to deny, reduce, or otherwise downcode a claim. A. Review B. Audit C. Grievance D. Appeal | D. Appeal |
| What feature in a PMP automatically posts the payment data in the RA to the correct account? A. Reconciliation B. Autoposting C. Payment posting D. Adjudication | B. Autoposting |
| Place the Medicare appeal process steps in order: - Redetermination - Medicare Appeals Council - Federal court (judicial) review - Administrative law judge - Reconsideration | 1. Redetermination 2. Reconsideration 3. Administrative law judge 4. Medicare Appeals Council 5. Federal court (judicial) review |
| In what situation is appealing a claim not necessary for Medicare-participating providers? A. If the claim was appealed and then paid B. If the claim was denied for major errors or omissions C. If the claim was paid even though there was an error D. If the claim was denied for minor errors or omissions | D. If the claim was denied for minor errors or omissions |
| What happens to the difference between the billed amount and the allowed amount unless it can be billed to the patient under the payer's rules? A. It is used to reconcile the statement. B. It is billed to the insurance. C. It is written off. D. It is appealed. | C. It is written off. |
| A(n) ______ audit might be conducted to check the documentation of the provider's cases or, in some cases, to check for fraudulent practices. A. Medicare B. Prepayment C. Postpayment D. Overpayment | C. Postpayment |
| Which of the following are typical problems of denial management? (MAY BE MORE THAN ONE) A. Procedures totally paid B. Procedures not paid C. Rejected claims D. Partially paid, denied, or downcoded claims | B. Procedures not paid C. Rejected claims D. Partially paid, denied, or downcoded claims |
| From the payer's point of view, ______ are improper or excessive payments resulting from billing errors for which the provider owes refunds. A. Postpayments B. Payments C. Overpayments D. Prepayments | C. Overpayments |
| Postpayment ______ by payers may change the initial determination of a claim. A. Denials B. Audits C. Renewals D. Considerations | B. Audits |
| The Fraud Enforcement and Recovery Act (FERA) of 2009 made major changes to which act by defining the act of keeping an overpayment from the federal government as fraud? A. False Claims Act (FCA) B. Fraud Claims Act C. Medicare Appeal Act D. Affordable Care Act | A. False Claims Act (FCA) |
| The person filing an appeal is the ______ or the appellant, whether that individual is a provider or a patient. A. Claimant B. Defendant C. Reviewer D. Appealer | A. Claimant |
| If a medical practice believes that an insurance company has treated it unfairly, it has the right to file a(n) ______ with the state insurance commission. A. Grievance B. Audit C. Appeal D. Lawsuit | A. Grievance |
| Postpayment reviews are used for which of the following? (MAY BE MORE THAN ONE) A. To study treatments and outcomes B. To eliminate postpayment reviews C. To build clinical information D. To verify the medical necessity of reported services E. To uncover fraud and abuse | A. To study treatments and outcomes C. To build clinical information D. To verify the medical necessity of reported services E. To uncover fraud and abuse |
| Which of the following are examples of overpayments on claims? (MAY BE MORE THAN ONE) A. The claim was paid twice. B. The provider collected a payment from the primary payer. C. The claim should have been denied or downcoded because the documentation did not support it. D. The provider may have collected a primary payment from Medicare when another payer is primary. | A. The claim was paid twice. C. The claim should have been denied or downcoded because the documentation did not support it. D. The provider may have collected a primary payment from Medicare when another payer is primary. |
| What is the next step to take when a patient has additional insurance coverage, after the primary payer's RA has been posted? A. File an appeal. B. Perform an audit. C. Call the insurance company. D. Bill the second payer. | D. Bill the second payer. |
| FERA encourages qui tam lawsuits, which extend the ______ protection to cover both contractors and agents of an entity, in addition to employees. A. Patient B. Insurance company C. Provider D. Whistle-blower | D. Whistle-blower |
| The second payer determines whether additional benefits are due under the policy's ______ provisions and sends payment with another RA to the billing provider. A. EOB B. COB C. RA D. PMP | B. COB |
| A grievance is a complaint filed by a practice with the state insurance commission against a ______. A. Payee B. Patient C. Provider D. Payer | D. Payer |
| When completing a paper claim, who completes the claim form and sends it with the primary RA attached? A. Medical insurance specialist B. Patient C. Primary insurance company D. Secondary payer | A. Medical insurance specialist |
| Benefits for a patient who has both Medicare and other coverage are coordinated under the rules of the ______ program. A. MSP B. COB C. PCP D. ACA | A. MSP |
| In which of the following situations is Medicare the secondary payer? (MAY BE MORE THAN ONE) A. When an individual is employed and is covered by the employer's group health plan B. When an individual must pay premiums to receive Part A coverage C. When an individual is working for an employer with twenty or fewer employees D. When an individual over age sixty-five is covered by a spouse's employer's group health plan | A. When an individual is employed and is covered by the employer's group health plan D. When an individual over age sixty-five is covered by a spouse's employer's group health plan |
| When billing the secondary payer for noncrossover claims, the medical insurance specialist prepares an additional claim for the secondary payer and sends it with a copy of what? A. PMP B. PCP C. RA D. EOB | C. RA |
| For ______ claims, the specialist reports a two-digit insurance type code under the MSP program. A. Secondary B. Electronic C. Paper D. Manual | B. Electronic |
| When does the practice not have to send a claim to the secondary payer? (MAY BE MORE THAN ONE) A. When the secondary payer handles the coordination of benefits transaction B. When the claim automatically crosses over C. When the primary payer handles the coordination of benefits transaction D. When the claim is not a crossover | B. When the claim automatically crosses over C. When the primary payer handles the coordination of benefits transaction |
| Which of the following are the three formulas for the completion of MSP claims? (MAY BE MORE THAN ONE) A. Lower allowed charge (either primary payer or Medicare) minus payment made on the claim B. Primary payer's allowed charge minus payment made on the claim C. What Medicare would pay (80 percent of Medicare allowed charge) D. Higher allowed charge (either primary payer or Medicare) minus payment made on the claim | B. Primary payer's allowed charge minus payment made on the claim C. What Medicare would pay (80 percent of Medicare allowed charge) D. Higher allowed charge (either primary payer or Medicare) minus payment made on the claim |
| If a paper RA is received, the procedure is to use the ______ to bill the secondary health plan that covers the beneficiary. A. UB-92 B. ICD-10-CM C. HIPAA 837P D. CMS-1500 | D. CMS-1500 |
| The claim that is sent to Medicare is automatically crossed over to Medicaid for ______ payment. A. Secondary B. Primary C. Crossover D. Tertiary | A. Secondary |
| If Medicare is the secondary payer to one primary payer, the claim must be submitted using the ______ transaction unless the practice is excluded from electronic transaction rules. A. CMS-1500 B. UB-92 C. HIPAA 837P D. ICD-10-CM | C. HIPAA 837P |
| In which of the following situations is Medicare the primary payer? (MAY BE MORE THAN ONE) A. When an individual is retired and receiving coverage under a previous employer's group policy B. When an individual is employed and is covered by the employer's group health plan C. When an individual is working for an employer with twenty or fewer employees D. When an individual is enrolled in Part B but not Part A of the Medicare program | A. When an individual is retired and receiving coverage under a previous employer's group policy C. When an individual is working for an employer with twenty or fewer employees D. When an individual is enrolled in Part B but not Part A of the Medicare program |
| How many formulas are used to calculate the amount of the patient's coinsurance that will be paid by Medicare under MSP? A. Three B. Four C. Two D. Five | A. Three |
| If a patient is covered by both Medicare and Medicaid, Medicare is ______. A. Secondary B. Tertiary C. Unapproved D. Primary | D. Primary |
| A payer's initial processing of a claim screens for A. Claims attachments B. Basic errors in claim data or missing information C. Utilization guidelines D. Medical edits | B. Basic errors in claim data or missing information |
| Some automated edits are for A. Medical necessity reduction denials B. Clinical documentation C. Patient eligibility, duplicate claims, and noncovered services D. Valid identification numbers | C. Patient eligibility, duplicate claims, and noncovered services |
| A claim may be downcoded because A. It does not list a charge for every procedure code. B. It is for noncovered services. C. The procedure code applies to a patient of the other gender. D. The documentation does not justify the level of service. | D. The documentation does not justify the level of service. |
| Payers should comply with the required A. Insurance aging report B. Retention schedule C. Claim turnaround time D. Remittance advice | C. Claim turnaround time |
| What is the next step after the primary payer's RA has been posted when a patient has additional insurance coverage? A. Billing the second payer B. Filing a grievance C. Posting the payment D. Filing an appeal | A. Billing the second payer |
| Appeals must always be filed A. By the provider for the patient. B. Within a specified time. C. With the state insurance commissioner. D. By patients on behalf of relatives. | B. Within a specified time. |
| Determine what should be verified after an RA has been checked for the patient's name, account number, insurance number, and date of service. A. That no further clarification is needed from the payer B. That all billed CPT codes are listed C. That no claims have been downcoded D. That the payment for each CPT code matches the expected amount | B. That all billed CPT codes are listed |
| If a patient has secondary insurance under a spouse's plan, what information is needed before transmitting a claim to the secondary plan? A. 276 data B. PPO data C. RA data D. 271 data | C. RA data |
| What type of codes explain Medicare payment decisions? A. CAGC B. CARC C. MOA D. RARC | C. MOA |
| Which of the following appears only on secondary claims? A. Primary plan name B. Primary insurance group policy number C. Primary payer payment D. Primary insurance employer name | C. Primary payer payment |
| Claim status when the payer is developing the claim | Suspended |
| Document describing a payment resulting from a claim adjudication | Remittance Advice |
| Electronic transaction for payment explanation | HIPAA X12 835 Health Care Payment and Remittance Advice |
| States' laws obligating carriers to pay clean claims within a certain time period | Prompt-Pay Laws |
| Claim status when the payer is waiting for information | Pending |
| Used on an RA to indicate the general type of reason code for an adjustment | Claim Adjustment Group Code |
| Explains payers' payment decisions | Remittance Advice Remark Code |
| Software feature enabling automatic entry of payments on a remittance advice | Autoposting |
| Comparison of two numbers | Reconciliation |
| Request for reconsideration of a claim adjudication | Appeal |
| Person/entity exercising the right to receive benefits | Claimant |
| One who appeals a claim decision | Appellant |
| Complaint against a payer filed with the state insurance commission by a practice | Grievance |
| A claim that is not paid due to incorrect information must be corrected and sent to the payer according to its procedures | Rejected Claim |
| If a procedure that should have been paid on a claim was overlooked, another claim is sent for that procedure | Procedure Not Paid |
| If the payer has denied payment, the first step is to study the adjustment codes to determine why. If a procedure is not a covered benefit or if the patient was not eligible for that benefit, typically the next step will be to bill the patient for the noncovered amount | Partially Paid Claim |
| A decision about the next action must be made. The options are to bill the patient, write off the amount, or challenge the determination with an appeal. Some provider contracts prohibit billing the patient if an appeal or necessary documentation has not been submitted to the payer | Denied or Downcoded Claim |
| A payer's refusal to pay for a reported procedure that does not meet its medical necessity criteria | Medical Necessity Denial |
| Improper or excessive payments resulting from billing errors for which the provider owes refunds | Overpayments |
| Letter from Medicare to an appellant regarding a first-level appeal | Medicare Redetermination Notice (MRN) |
| Analysis of how long a payer has held submitted claims | Insurance Aging Report |
| Software feature enabling automatic entry of payments on an RA | Autoposting |
| Claim status indicating that the payer is waiting for additional information | Pending |
| Payer action to gather clinical documentation and study a claim before payment | Development |
| A banking service for directly transmitting funds from one bank to another | Electronic Funds Transfer (EFT) |
| Medical situation in which a patient receives extensive independent care from two or more attending physicians on the same date of service | Concurrent Care |
| A payer's decision regarding payment of a claim | Determination |
| Code used on an RA to indicate the general type of reason code for an adjustment | Claim Adjustment Group Code |
| Federally mandated program that requires private payers to be the primary payers for Medicare beneficiaries' claims | Medicare Secondary Payer (MSP) Program |
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