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The concept that every procedure or service reported to a third-pary payer must be linked to a condition that justifies the procedure or service is called
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Which is a typical responsibility of a health insurance specialist?
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MED INS
medical insurance
| Question | Answer |
|---|---|
| The concept that every procedure or service reported to a third-pary payer must be linked to a condition that justifies the procedure or service is called | neccesity |
| Which is a typical responsibility of a health insurance specialist? | correcting claims processing errors |
| The mutual exchange of information bea tween providers and payers is called electronic | data interchange |
| The document submitted by provider to a third-party for purpose of requesting reimbursement for services provided is a(n) | claim |
| The process of classifying diagnoses, procedures, and services is called | coding |
| Which coding system is used for reporting procedures and services in physician's offices? | CPT |
| Diagnoses are coded according to | ICD-9-CM |
| Rules that govern the conduct of members of a profession are called | ethics |
| Physicians offices should bond employees who have which responsibilty? | financial |
| Which term is another word for stealing money? | embezzling |
| A claim was submitted for a left shoulder x-ray on an elderly patient, and the diagnosis reported on the claim was urinary tract infection. The claim was rejected because | medical necessity not met |
| The type of healtha care that helps individuals avoid health and injury problems is | preventive |
| Which is a government-sponsored health program that provides benefits to low-income | medicaid |
| The standard claim developed by CMS and used to report procedures and services delivered by physicians is called the | CSM-1500 |
| The act passed in 1996 that has had a great impact on confidentiality, electronic informatin transmission, and standardization is the | HIPPA |
| Which three components constitute the RBRVS payment system? | physician work, practice expense, and malpractice insurance expense |
| Insurance that is available through employers, labor unions, consumer health cooperatives, and other organizations is | Group health insurance |
| A provider's list of predetermined payments for healthcare services to the patients is known as | fee schedule |
| Which termin describe the process of developing patient care plans for coordination and provision of care for complicated cases in a cost=effective manner? | case management |
| Mandates are | laws |
| Employees and dependents who join a managed care plan are caler ed | subscribers |
| Which act or amendment established an employee's right to continue healthcare coverage beyond a scheduled benefit of termination date? | COBRA of 1985 |
| If a plan allows enrollees to seek care from non-network providers, what effect will this have on the enrollees who sees a non-network provider? The enrollee will | pay higher out of pocket costs |
| The specified percentage or charges the patient must pay to the provider for each service received or for each visit is the | coinsurance |
| Data transmitted electronically or manually to payers or clearinghouses is claims | submission |
| W hen the provider is required to receive as payment in full whatever amount the insurance reimburses for services, the provider is agreeing to | accept assignment |
| The person responsible for paying the charges for services rendered by the provider is the | guarantor |
| Which document is used to generate the patient's financial and medical record? | patient registration form |
| The rule stating that the policyholder whose birth month and day occur earlier in the calendar year holds the primary policy for dependent children is the ...rule | birthday |
| The insurance industry is regulated by whom? | individual states |
| Federal and state statutes are | passed by legislative bodies |
| Breach of confidentiality can result from | discussing patient healthcare informatin with unauthorize sources |
| The recognized difference between fraud and abuse is the | intent |
| Undated signed forms are assumed to be valid until revoked by the patient or | guardian |
| When a Medicare provider commits fraud, which entity conducts the investigation? | Office of Inspector General |
| The diagostic statements "urinary tract infection due to E.Coli" require ...codes to be assigned | two |
| Which convention is used to display a series of terms that can modify the statement to its right? | braces- |
| In th Ce ICD-9-CM, italized codes signify that | more than one code is required to fully describe a diagnosis |
| Type 2 diabetic c cataract, right eye | 250.50, 366.41 |
| The ICD-9-CM syStem classifies | morbidity |
| The ICD-9-CM V codes classify | factors influencing healh status |
| When reporting CPT codes on the CMS-1500 claim,medical necessity is proven by | linking the CPT code to its ICD-9-CM counterpart |
| A black triangle located to the left of CPT code indicates that the code | has been revised from previous CPT publications |
| Initial office visit for a patient with left knee pain. Detailed history and examination ws documented, along with low-complexity medical decision making | 99203 |
| According to CPT, prolonged services codes are assigned in addition to other E/M services when treatment exceeds the time included in the CPT description by | 30 minutes |
| HCPCS is a multilevel coding system that contains | two levels; level one, level two |
| Which statement is true of durable medical equipment? | it can withstand repeated use |
| Which special codes allow payers the flexibility of establishing codes if they are needed before the next January 1 annual date? | temporary |
| Each relative value component is multiplied by the geographic cost practice (GCPI), and then each is further multiplied by a variable figure called the | conversion factor |
| Non-participating (nonPAR) providers are restricted to billing at or below the | limiting charge |
| Medicare participating providers commonly report actual fees to Medicare but adjust fees after payment is received. The difference between the fee reported and the payment received is a | write-off |
| "Indicent to" relates to services provided by nonPARs that are defined as services | provided incidental to other services provided by the physician |
| The prospective payment system dependent on the patient's principal diagnosis, comorbidities, complications, and principal and secondary procedures are called | diagnosis-related groups (DRGs) |
| What term is used to describe the types and categories of patients treated by a healthcare faciity or provider? | case mix |
| The Medicare physician fee schedule amount for code 99210 is $100; the participating provider's usual charge for this service is $125. Calculate Medicare reimbursement amount | =$80 |
| Th e first-listed diagnosis reported on a CMS-1500-CM claim form is the | major reason the patient sought medical care |
| The concept of linking diagnosis codes with the procedure/services codes is called | medical necessity |
| When a provider documents justification for a patient seeking healthcare services, but no disorder is documented, the health insurance specialist usually assigns a(n) | V code |
| The patient is a 39-year old female patient on lithium who is unable to discontinue the medication and does not desire to become pregnant while on medication. The patient therefore desires surgical sterilization. | V26.51: 58673 |
| The diagnosis code reported in item 1, Block 21, of the CMS-1500 claim form is | first-listed diagnosis |
| Items 1-4 Block 21 of CM-1500 claim link listed diagnosis codes to their appropriate procedure service codes reported Block 24; known as....numbers | pointer |
| The maximum number of CPT/ and or HCPCS modifiers that can be reported in block 24 on CMS-1500 is | four |
| Block 25 claim requires entry of either provider's soc.securty number or | EIN |
| What is reported in Block 24EE of the CMS-1500? | diagnosis pointer number |
| The birthday rule applies when dependent children living at home are covered by more than one health insurance policy. The primary policy is determined by the parent | who has birthday that occurs first in the calendar year |
| The is covered by two health insurance policies, his own employer's group plan and his spouses' employer's group health plan. Which is primary policy? | The patient's" own policy is primary |
| When an "X" appears in the YES box in Block 10a of CMS-1500 claim, it indicates | the services provided were related to auto-accident injury |
| To prevent breach of confidentiality, the patient must either sign an "Authorization for Release of Medical Information" (ROM) or | Sign Block 12 of the CMS-1500 claim form |
| Which diagnosis is considered a chronic- icondition that would always affect the patient care? | diabetes mellitus |
| If laboratory procedures are performed in provider's office, how is it indicated on the CMS-1500 form? | by entering X in NO block 20 |
| Which of following is considered commercial health insurance company: | Aetna |
| Losses to third-party caused by the insured, by an object owned by the insured, or on the premises of the insured are covered by ....insurance | liablity |
| Which term describes the contractual right of third-party payer to recover healthcare expenses from liable party? | subrogration |
| The amount commonly charged for a specific medical service by providers within a particular geographic region is known as | usual,customary, and reasonable rate |
| Which is considered a place of service for purposes of Block 2 | nursing facility |
| Enter an X in the YES Block 27 to indicate | accept assignment |
| Disability insurance typically provides what type of compensation to the injured person? | financial |
| A participating provider is one who enters into a contract with BlueCrossBlueShield corporation and agrees to | bill patients only deductible and copay/coinsurance amounts |
| Which offers discounted healthcare services to subscribers who use designated healthcare providers but who also provides coverage for services rendered by healthcare providers who are NOT part of the network? | preferred provider organization |
| Which concept applies to BCBS directly reimburses participating providers for healthcare services rendered to subscribers? | assignment of benefits |
| Business entities that pay taxes on profits generated by the corporation and distribute after-tax profits to shareholders and officers are .......organizations | for-profit |
| tA special clause written into a contract that stipulates addtional coverage over and above the standard contract is a(n) | Rider |
| Which feature makes BCBS plan different from other commercial plans? | BCBS provides billing manuals and newsletters to keep PARs up-to-date on insurance procedures |
| Medicare is available to an individual who has worked at least | 10 years in Medicare-covered employment, is at least 65 years of age, and is citizen of USA |
| The general enrollment period for Medicare Part B coverage | is held January 1 through March 31st each year |
| A Medicare benefit period begins | with the first day of hospitalization and ends when the patient has been out of the hospital for 60 consecutive days |
| A Medicare private contract is an agreement betwee the Medicare beneficiary and physician who has "opted out" of Medicare for two years. | the physician cannot bill for any service or supplies provided to any Medicare beneficiary for two years |
| Individuals automatically enrolled in Medicare Part A are those who | already receive Social Security, Railroad Retirement Board, or disability benefits and are not yet 65 |
| Medicare Supplementary Insurance is also called | Medigap |
| The purpose of the advance beneficiary notice is to alert the patient that | a service is unlikely to be reimbursed by Medicare and that the patient must guarantee payment for services |
| The deadline for filing Mediare claims is | December 31 of the year in which the service was provided |
| Certain individuals who have resources at or below twice the standard allowed under the SSI program and income who have resources at or below 100% of the FPL do not have to pay mon Medicare premiums, deductibles,and coinsurance; are categorized as | qualified Medicare beneficiaries |
| The Medicaid program that makes cash assistance available on a time-limited basis for children deprived of support because of parent's death,incapacity,absence, unemployment is the | temporary assistance to needy families |
| How frequently should a patient's Medicaid eligibility be verified? | with each visit to provider |
| States rarely require Medicaid recipients to pay a | premium |
| Medicaid will conditionally subrogate claims | when there is liability insurance to cover a person's injuries |
| Block 23 of CMS-1500 claim contains the Medicaid......number, if applicable | preauthorization |
| Which of the following practices is prohibited by law? | balance billing of Medicaid patients |
| TRICARE is a healthcare program for | active duty members of the military and their qualified family members |
| TRICARE Standard enrollees are responsible for paying aor n annual.......as well as copayments | deductible |
| A comprehensive healthcare program for which the Department of Veteran Affairs (VA) theshares the costs of covered healthcare services and supplies/supports with eligible beneficiaries is called | CHAMPVA |
| What system is used to confirm TRICARE eligibility for sponsors and their dependents? | Defense Enrollment Eligibilty Reporting System |
| Block 31 of CMS-1500 claim submitted to TIRCARE must contain | the name and credentials of the provider |
| The worker's compensation First Report of Injury fos rm is completed when the | patiens first seeks treatment for work-related injury or illness |
| What is the definition of temporary partial disability? | the employee's wage earning capacity is partially lost but only on a temporary basis |
| The type of worker's compensation claim that is the easiest to process is | medical treatment |
| The person responsible for completing the First Report of Injury is the | treating physician |
| A worker's compensation progress report is filed when | there is any significant change in the worker's medical or disability |
| An employee will lose the right to worker's compensation coverageif the injury results solely from | drug or alcohol intoxication |
| Worker's compensation premiums are paid by the | employer |
| What information is entered Block 11 of CMS-1500 form for workmen's compensation | the worker's compensation claim number |
| Worker's compensation laws protect the employer by | limiting the award an injured employee can recover from an employer |
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IndyGirl89