chapter 09 insurance
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| time limits stated in individual health insurance policies about an insurance company's obligation to pay benefits are the same for all insurance companies | false
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| there is standardization of format for the explanation of benefit document for all private insurance carriers | false
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| the insurance industry is protected by a special exemption from the federal trade commission | true
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| insurance companies are rated according to the number of complaints received about them | true
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| the status of electronic insurance claims may be accessed quickly electronically or telephonically by digital response systems | true
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| inquires about insurance claims may be in writing or by telephone | true
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| a rejected insurance claim should be corrected and sent in for review or appeal | true
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| approximately 50% of individuals purse appeals on denied insurance claims | false
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| in the case of a medicare part B redtermination, carriers have been instructed to pay an appealed insurance claim if the cost of the hearing process is more than the amount of the claim | true
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| if you have a denied insurance claim, you should change the information and resubmit the claim | false
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| routine use of too many nonspecific diagnostic codes may result in down coding | true
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| In any type of over payment situation, always cash the third party check and write a refund check | false
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| If a provider is notified by a commercial insurance carrier that a overpayment has been made, investigate the refund request | true
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| a level 1 medicare redetermination (appeal) may be by telephone or in writing or by submitting a CMS-2007 Form | true
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| a peer review is usually done before the appeal process | false
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| appeal decisions on Medicare unassigned insurance claims are sent to the patient | true
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| the highest level of a medicare redetermination is with an administrative law judge hearing | false
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| If an insured is in disagreement with the insurer for the settlement of a claim, a suit must begin within | 3 years
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| If a payment problem develops with an insurance company ignores claims and exceeds time limits to pay a claim, it is prudent to contact the | state insurance commissioner
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| the document together with the payment voucher that is sent to the physician who has accepted assignment of benefits is referred to as a | EOB
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| when receiving payment from a private insurance carrier, check the amount on the EOB with the | copy of the CMS-1500 form
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| an insurance claims register provides a | follow up procedure for insurance claims
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| pending or resubmitted insurance claims may be tracked through a | tickler file
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| there are several ways to file pending insurance claims. What is the best way to file so that timely follow-up can be made | file by patient's last name
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| a follow up effort made to an insurance company to locate the status of an insurance claim is called an | inquiry and tracer
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| if an insurance claim has been lost by a insurance carrier the procedure to follow is | ask if there is a backlog of claims, submit a copy of the original claim, and verify the correct mailing address
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| An example of a technical error on a insurance claim is | duplicate dates of service, transposed numbers, missing place of service code
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| An insurance claim with an invalid procedure code would be | rejected
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| what should you do if an insurance carrier requests information about another insurance carrier | Provide the information
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| an insurance claim with an invalid procedure code would be | rejected
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| an insurance claim for a service that has been bundled with other services would be | denied
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| an insurance claim for which prior approval was not obtained would be | denied
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| the total number of levels of redetermination that exist in the medicare program is | 5
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| the first level of appeal in the medicare program is | redetermination
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| the correct method to send documents for a medicare reconsideration (level 2) by | certified mail with return receipt requested
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| a request for a medicare administrative law judge hearing can be made if the amount controversy is at least | $130
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| How many levels of appeals for tricare | 3
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| Tricare appeals are normally resolved in | 60days
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| in a Tricare case, a request for an independent hearing may be pursed if the amount in question is | 300 or more tricare
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| the total number of levels of redetermination that exist in the medicare program is | 5
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| the first level of appeal in the medicare program is | redetermination
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| the correct method to send documents for a medicare reconsideration (level 2) by | certified mail with return receipt requested
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| a request for a medicare administrative law judge hearing can be made if the amount controversy is at least | $130
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| How many levels of appeals for tricare | 3
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| Tricare appeals are normally resolved in | 60days
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| in a Tricare case, a request for an independent hearing may be pursed if the amount in question is | 300 or more
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| an insured person cannot bring legal action against an insurance company until | 60 days after a claim
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| documentation form private insurance carriers sent to participating providers that accompanies payment and describes the response to a claim is referred to by the acronym | EOB
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| FTC | Federal trade commission
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| Monitoring the activities of insurance companies and making sure that the interest of the policyholders are protected are the jobs of the | insurance commission
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| all request of the insurance commissioner must be submitted in writing and include the | patients signature
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| a delinquent insurance claim may be easily located by reviewing the | insurance claim register
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| a suspense or follow-up file used to track pending insurance claims are called a | tickler file
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| overdue payment on a insurance claim is referred to as | delinquent claim
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| an insurance claim that is processed without following specific insurance carrier instructions is considered an | rejected claim
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| if the medical practice receives payment from an insurance company that is more than the contract rate, it is called | overpayment
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| Generally if a bill has not been paid, the physician rebills the patient every | 30 days
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| If inadequate payment was received from an insurance company procedure, the insurance billing specialist should file an | appeal on behalf of the physician
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| a request for a hearing before an administrative law judge( in a medicare case) may be made if the amount still in question is | $130.00 or more
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Created by:
hudsondrummerman