Includes Review for chapters 1-5

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Answer

To remain up-to-date with the frequent changes of health insurance processing, health insurance specialists should:

make certain they are on mailing lists to receive newsletters from third-party payers remain current on news released by the CMS Stay current with the DHHS updates

🗑

The process of reporting diagnoses, procedures, and services as numeric and alphanumeric characters on the insurance claim is called:

coding

🗑

Another name for health insurance specialist is:

Reimbursement specialist

🗑

What involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity of performing that procedure or service?

Medical necessity

🗑

ICD-9-CM stands for:

International Classification of Diseases-Ninth Revision, Clinical Modification

🗑

What does CPT stand for?

Current Procedural Terminology

🗑

A successful health insurance specialist should have which of the following characteristics:

Attention to details Strong sense of ethics Ability to work independently

🗑

Health insurance is available to:

Individuals who participate in the individual (personal) health plans Participants of a prepaid health plan Individuals who participate in group (employer-sponsored) health plans

🗑

Reimbursement for income lost as a result of temporary or permanent illness or injury is:

Disability insurance

🗑

What is the program mandated by federal and state governments that requires employers to cover medical expenses and loss of wages for workers who are injured on the job?

Workers' compensation

🗑

The CMS-1500 claim form is used to report:

Professional services Technical services

🗑

The ________ is the person responsible for paying the charges

Guarantor

🗑

__________ is the insurance plan responsible for paying health care insurance claims first

Primary insurance

🗑

When children are covered by the insurance policies of both parents, the ________ states that the parent whose birth month and day occurs earlier in the calendar year holds the primary policy

Birthday rule

🗑

The patient ledger is also known as the:

Patient account record

🗑

In 1996, Congress passed the ________ because of concerns about fraud and abuse.

Health Insurance Portability and Accountability Act

🗑

The most common form of Medicare fraud is:

Billing for services not provided Misrepresenting the diagnosis to justify payment Soliciting, offering, or receiving a kickback

🗑

Which of the following is not an example of abuse?

Excessive charges for services, equipment, or supplies

🗑

Standards of laboratory testing

CLIA

🗑

Forerunner of today's managed care plans

Medicare

🗑

Contract that protects from loss

Insurance

🗑

Weekly benefit amount divided into quarters

Base period

🗑

Healthcare services to subscribers in a given geographical area for a fixed fee

HMO

🗑

Promotes correct coding methodologies

NCCI

🗑

Identification of disease and provision of care

Medical care

🗑

Amount the patient is financially responsible for before an insurance policy provides payment

Deductible

🗑

Specified amount paid for each physician visit

Major Medical Insurance

🗑

Patient visit documentation

Patient record

🗑

Title XIX of the SSA of 1965

Medicaid

🗑

Percentage of cost patient shares with the health plan

Coinsurance

🗑

Protection from occupational hazards in the workplace

OSHA

🗑

Insurance plan responsible for paying claims first

Primary insurance

🗑

Clearinghouse that involves vendors, like banks, in the processing of claims

Value-added network (VAN)

🗑

Hospital financial record source document

Electronic flat file

🗑

Electronic format standard that uses a variable length file

ANSI ASC X12

🗑

Primary policy determination for covered children

Birthday rule

🗑

Physician does not contract with the insurance plan

Non-PAR

🗑

Chronological summary of all transactions posted on a specific day

Patient account record

🗑

Reported on claims to provide clarification about procedures and services performed

Modifiers

🗑

Supporting documentation associated with a healthcare claim or patient encounter

Claim attachment

🗑

Father's plan is always primary when child is covered by both parents

Gender rule

🗑

Maximum amount the payer will allow for a procedure or service

Allowed charges

🗑

Physician's financial record source document

Encounter form

🗑

Payment Error and Prevention Program

PEPP

🗑

Medicare Prescription Drug, Improvement, and Modernization Act of 2003

MMA

🗑

Recovery Audit Contractor

RAC

🗑

False Claims Act

FCA

🗑

Tax Equity and Fiscal Responsibility Act of 1983

TEFRA

🗑

Balanced Budget Refinement Act of 1999

BBRA

🗑

Health Insurance Portability and Accountability Act of 1996

HIPAA

🗑

Omnibus Consolidated and Emergency Supplemental Appropriations Act of 1999

OCESAA

🗑

Consumer-direct Health Plan

CDHP

🗑

Group Practice Without Walls

GPWW

🗑

Point-of-Service Plan

POS

🗑

Individual Practice Association

IPA

🗑

Preferred Provider Organization

PPO

🗑

Physician-Hospital Organization

PHO

🗑

State Children's Health Insurance Program

SCHIP

🗑

Exclusive Provider Organization

EPO

🗑

The Medicare Catastrophic Coverage Act of 1988 mandated the reporting of ICD-9-CM diagnosis codes on what type of claims?

All Medicare claims

🗑

An outpatient is a person treated in which of the following settings:

Hospital observation unit Ambulatory surgery center Physician's office

🗑

Patients signs Block 13 of the CMS-1500 claim to instruct the payer to directly reimburse the provider; this is an

Assignment of benefits

🗑

The concept that every procedure or service reported to a third-party payer must be linked to a condition that justifies that procedure or service is called medical

necessity

🗑

Which codes supplement procedures, services, and supplies not classified in CPT?

HCPCS level II

🗑

Which is a typical responsibility of a health insurance specialist?

Correcting claims processing errors

🗑

Which organization offers a payer certification exam?

AAPC

🗑

The mutual exchange of information between providers and payers is called electronic

data interchange

🗑

Conduct and qualities that characterize a professional person are called

professionalism

🗑

The abbreviation for the Health Common Procedure Coding System

HCPCS

🗑

The document submitted by a provider to a third-party for the purpose of requesting reimbursement for services provided is a

claim

🗑

The process of classifying diagnoses, procedures, and services is called

coding

🗑

The process of taking and passing credentialing exams (e.g., CPC) is called professional

certification

🗑

Which coding system is used for reporting procedures and services in physician offices?

CPT

🗑

Diagnoses are coded according to

ICD-9-CM

🗑

Health insurance specialists play an important role in what process involving denied or underpaid claims?

Appeal

🗑

Electronic data interchange is achieved by using

a standardized, machine-readable format

🗑

Rules that govern the conduct of members of a profession are called

Ethics

🗑

The notice received by a provider from a payer that contains payment information for a claim is the

remittance advice

🗑

A coding consultant who is paid by a practice to assist the coding and billing staff would most likely be classified as an

independent contractor

🗑

Which is another name for professional liability insurance?

Errors and omissions insurance

🗑

Physician offices should bond employees who have which responsibility?

Financial

🗑

Which term is another word for stealing money?

Embezzling

🗑

A customer was severely injured in a grocery store when a pallet of soda cans toppled onto him. Which insurance would be billed for the customer's medical care?

Liability

🗑

Which type of insurance provides financial and medical benefits for an injured employee?

Workers' compensation

🗑

Health information management professionals can achieve coding certification by successfully passing an exam offered by which professional association?

AHIMA

🗑

The study of the body and its structures is

anatomy

🗑

The study of disease processes and abnormalities of the body is

pathophysiology

🗑

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 was not met

🗑

A patient was diagnosed with asthma. Which coding system is used to report this condition on the claim?

ICD-9-CM

🗑

The type of health care that helps individuals avoid health and injury problems is

preventive

🗑

In 1916, this law replaced the 1908 workers' compensation legislation, and civilian employees of the federal government were provided medical care, survivors' benefits, and compensation for lost wages.

Federal Employees' Compensation Act

🗑

During World War II, the government restricted the wages employers could offer employees; thus, employers began offering which of the following to their employees?

Benefits

🗑

When three or more doctors deliver health care and make joint use of equipment, supplies, and personnel, this is called a

group practice

🗑

Which coding system is used to report procedures and services on physician office insurance claims?

CPT

🗑

Which is a government-sponsored health program that provides benefits to low-income patients?

Medicaid

🗑

The specified amount of annual out-of-pocket expenses for covered health care services that the insured must pay annually for health care is called the

deductible

🗑

The standard claim developed by CMS and used to report procedures and services delivered by physicians is called the

CMS-1500

🗑

What coding system was originally developed by the World Health Organization in 1948?

ICD

🗑

The act passed in 1997 that resulted in the development of coding compliance programs by the federal government is the

BBA

🗑

The act passed in 1996 that has had a great impact on confidentiality, electronic information transmission, and standardization is the

HIPAA

🗑

The Veterans Healthcare Expansion Act of 1973 authorized the VA to establish what to provide health care benefits for dependents of veterans rates as 100% permanently and totally disabled as a result of service-connected conditions, veterans who died

CHAMPVA

🗑

The ambulatory payment classification prospective payment system is used to reimburse claims for what service?

Outpatient

🗑

The percentage of costs a patient shares with the health plan is the

coinsurance

🗑

The Health Maintenance Organization Assistance Act of what year authorized federal grants and loans to private organizations that wished to develop HMOs, which are responsible for providing health care services to subscribers in a given geographic area

1973

🗑

The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) includes a payment classification system that reflects differences in patient resource use and costs, replacing which payment system with a per diem IPF PPS?

Cost-based

🗑

The Standard Unique Health Identifier for Health Care Providers or National Provider Identifier (NPI), was implemented in

2005

🗑

What is the purpose of third-pary administrators (TPAs)?

Administer health care plans and process claims

🗑

The federal legislation passed in 1981 that expanded the Medicare and Medicaid programs was

OBRA

🗑

Which three components constitute the RBRVS payment system?

Physician work, practice expense, and malpractice insurance expense

🗑

In which year was the first recognized commercial insurance company policy developed in the United States?

1860

🗑

An official from Baylor University in Dallas developed what is recognized now as the first example of which policy?

Blue Cross

🗑

Insurance that is available through employers, labor unions, consumer health cooperatives, and other organizations is

group health insurance

🗑

The type of insurance that provides coverage for catastrophic or prolonged illnesses and injuries is

major medical

🗑

A provider's list of predetermined payments for health care services to patients is known as the

fee schedule

🗑

Which term describes the process of developing patient care plans for the coordination and provision of care for complicated cases in a cost-effective manner?

Case management

🗑

The National Committee on Quality Assurance is a nonprofit organization that

measures and evaluates the quality of a managed care plan's performance

🗑

Employees and dependents who join a managed care plan are called

subscribers

🗑

Mandates are

laws

🗑

The review for appropriateness and necessity of care provided to patients, prior to the administration of care or retrospectively, is called

utilization management

🗑

Which type of HMO offers subscribers health care services by physicians who remain in their individual office settings?

Independent practice association

🗑

Which act or amendment established an employee's right to continue health care coverage beyond a scheduled benefit termination date?

COBRA of 1985

🗑

The 1988 Amendment to the HMO Act of 1973 added which provision?

Federally qualified HMOs could permit members to occasionally use non-HMO providers and be partially reimbursed

🗑

A risk contract is defined as an arrangement among health care providers

to make available capitated health care services to Medicare beneficiaries

🗑

If an HMO has met the federal standards established in the HMO Act of 1973, the HMO can be

federally qualified

🗑

If a plan allows enrollees to seek care from non-network providers, what effect will this have on the enrollee who sees a non-network provider? The enrollee will

pay higher out-of-pocket costs

🗑

Illegal wording in a managed care contract that prohibits a provider from discussing all possible treatment options with a patient is what kind of a clause?

Gag

🗑

Which type of managed care plan provides benefits to subscribers if they receive services only from network providers?

Exclusive provider organization

🗑

A medical group that has been specially formed to service a particular HMO is part of what type of HMO?

Closed panel

🗑

The newly emerging health plan that focuses on asking employees to be more responsible for health care decisions and cost sharing is what kind of health plan?

Consumer-directed

🗑

When a provider receives a fixed amount to provide only the care that an individual needs from that provider, this is known as what kind of payment?

Subcapitation

🗑

When a number of people are grouped for insurance purposes, this is known as a

risk pool

🗑

A triple option plan can also be known as a cafeteria plan or a

flexible spending plan

🗑

Which combines health care delivery with financing of services provided?

Managed care

🗑

Which 2003 legislation allows tax deduction for amounts contributed to a health savings account?

Medicare Modernization Act (MMA)

🗑

Managed care plans can contract with an outside vendor to establish and maintain a utilization management program. The plan can contract with a TPA or with a

utilization review organization (URO)

🗑

The voluntary process that a health care facility or organization undergoes to demonstrate it has met requirements beyond those required by law is called

accreditation

🗑

The patient account record that can be found in automated or manual format is also called the

patient ledger

🗑

The specified percentage of charges the patient must pay to the provider for each service received or for each visit is the

coinsurance

🗑

The financial record source document used to record services rendered in a physician's office is the

encounter form

🗑

When the provider is required to receive as payment in full whatever amount the insurance reimburses for services, the provider is agreeing to

accept assignment

🗑

Care rendered to a patient that was not properly approved (e.g., preapproved) by the insurance company is known as

unauthorized services

🗑

The maximum amount the payer will allow for each procedure or service, according to the patient's policy, is the

allowed charge

🗑

Approximately how many insurance claims are filed each year?

More than 6 billion

🗑

Processing a claim begins at the

Provider's office

🗑

Data transmitted electronically or manually to payers or clearinghouses is called claims

submission

🗑

According to the national standards mandated by HIPAA for the electronic exchange of administrative and financial care transactions, which would be a covered entity?

Managed care organization

🗑

Which organization facilitates the development of standards for health informatics and other industries, such as the international exchange of goods and services?

ANSI

🗑

If a claim is found to contain all data elements needed for processing, it is known as what kind of claim?

Clean

🗑

A procedure reported on a claim that is not included on the master benefit list will result in what?

Denial

🗑

The remittance advice is called what by the Medicare program?

Provider Remittance Notice (PRN)

🗑

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 what rule?

Birthday

🗑

To save the expense of mailing invoices to patients, the office may ask the patient to

pay the patient's portion of the bill before treatment or before the patient leaves the office

🗑

How long must providers retain copies of government insurance claims?

6 years

🗑

What type of claim is generated for providers who do not accept assignment?

Unassigned

🗑

The process of submitting multiple CPT codes when one code should be submitted is

unbundling

🗑

The insurance industry is regulated by whom?

Individual states

🗑

The processing of a claim consists of how many stages?

Four

🗑

Which allows for the direct submission of claims to payers using internet technology that emulates a system connection?

Extranet

🗑

When a provider performs a procedure for which there is no CPT or HCPCS level II code available, what must be provided to the payer?

Supporting documentation

🗑

Federal and state statues are

passed by legislative bodies

🗑

Which term describes guidelines written by administrative agencies, such as CMS, that are based on laws passed by legislative bodies?

Regulation

🗑

Case law is based on court decisions that establish precedent and is also called what?

Common law

🗑

Which is the legal newspaper published daily by the National Archives and Records Administration (NARA) of the federal government?

Federal Register

🗑

When a patient signs a release of medical information at a physician's office, that release is generally considered to be valid

for 1 year from the date entered on the form

🗑

Breach of confidentiality can result from

discussing patient health care information with unauthorized sources

🗑

Which term describes an individual's right to keep health care information from being disclosed to others?

Privacy

🗑

Practices that submit hard-copy insurance claims obtain that patient's signature in Block 12, which is what block on the CMS-1500 claim?

Release of medical information

🗑

The safekeeping of patient information by controlling access to hard-copy and computerized records is a form of

security management

🗑

Undated signed forms are assumed to be valid until revoked by the patient or

guardian

🗑

Information that is converted to a secure language format for electronic transmission is what kind of data?

Encrypted

🗑

Which federal legislation was enacted in 1995 to restrict the referral of patients to organizations in which providers have a financial interest?

Stark II laws

🗑

Testimony under oath taken outside the court (e.g., at the provider's office) is a

deposition

🗑

An organization that contracts with CMS to process fee-for-service health care claims and perform program integrity tasks for Medicare Parts A and B is called a Medicare

administrative contractor

🗑

In which year was the False Claims Act originally passed?

1863

🗑

Which act of legislation requires Medicare administrative contractors to attempt the collection of overpayments made under the Medicare or Medicaid programs?

Federal Claims Collection Act

🗑

Excessive charges for services, equipment, or supplies is an example of

abuse

🗑

The recognized difference between fraud and abuse is the

intent

🗑

When a Medicare provider commits fraud, which entity conducts the investigation?

Office of the Inspector General

🗑

A provider or beneficiary can receive a waiver of recovery of overpayment in which situation?

The beneficiary was without fault with respect to the overpayment and recovery would cause financial hardship.

🗑

As party of the administrative simplification provision of HIPAA, which of the following unique identifiers is assigned to third-party payers?

National Health PlanID (PlanID)

🗑

The HIPAA privacy rule states that "an individual has the right to inspect and obtain a copy of what information in a designated record set", except for psychotherapy notes, information compiled in anticipation of use in a civil, criminal, or administrati

Protected health

🗑

The threat of excessive awards in medical liability cases has increased providers' liability insurance premiums, resulting in what?

Increased health care costs

🗑

What is the best way to verify the identity of a caller requesting medical information?

Use the call-back method

🗑

The purpose of the Correct Coding initiative is to

reduce Medicare program expenditures

🗑

What organization is responsible for the health of a group of enrollees and can be a health plan, hospital, physician group or health system?

Managed Care Organization

🗑

A fee schedule is

a cost-based fee-for-service reimbursement methodology

🗑

TRICARE includes three plan options. Which of the following is not one of those options?

TRICARE select

🗑

The check-in procedure for a patient who is ________ to the provider's office is more extensive than for a ________ patient.

new; returning

🗑

This type of insurance provides coverage for catastrophic or prolonged illness and injuries:

major medical insurance

🗑

This is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees' health status, age, sex, and occupation.

Risk pool

🗑

Providers who send data in a standardized machine-readable format to an insurance company via disk, telephone modem, or cable are implementing:

electronic claims processing

🗑

Medical necessity is the measure of whether a health care procedure or service is appropriate for:

diagnosis and/or treatment of condition

🗑

The health care plan that reimburses providers for individual health care services provided is a:

fee-for-service plan

🗑

Provider's notification regarding payment of claim

Remittance advice

🗑

Liability insurance for providers

Medical malpractice insurance

🗑

Prior approval

Preauthorization

🗑

Diagnostic codes

ICD-9-CM

🗑

Certified Professional Coder

AAPC

🗑

Patient not responsible for paying what the plan denies

Hold harmless clause

🗑

Reporting diagnoses, procedures, and services

Coding

🗑

Principles of right or good conduct

Ethics

🗑

HCPCS level I codes

CPT

🗑

Physician

Health care provider

🗑

Results of processing a claim sent to patient

EOB

🗑

Exchange of data between provider and insurance company

Electronic Data Interchange

🗑

Errors and omissions insurance

Professional liability insurance

🗑

Physician's legal responsibility for actions of employees

Respondeat superior

🗑

National codes

HCPCS level II codes

🗑

Which act mandates regulations that govern privacy, security, and electronic transactions standards for health care information?

Health Insurance Portability and Accountability Act of 1996

🗑

The ________ mandates the retention of patient records and health insurance claims for a minimum of 6 years, unless state law specifies a longer period

HIPAA

🗑

If preauthorization for treatment by specialists and post-treatment reports were not filed, the claim would be:

denied

🗑

The Occupational Safety and Health Administration Act of 1970 was designed to:

protect all employees against injuries in the workplace

🗑

Liability insurance claims are made to:

cover the cost of medical care for traumatic injuries or lost wages

🗑

Accurate coding of diagnoses, procedures, and services rendered to the patient allows a medical practice to:

Facilitate analysis of the practice's patient base for improvement and efficiency Communicate diagnostic and treatment data to insurance plans for maximum recovery of benefits

🗑

________ is the storage of documentation for an established period of time, usually mandated by federal and/or state law.

Record retention

🗑

An exclusive provider organization (EPO) is similar to:

HMO

🗑

Recovery Audit Contractor

RAC

🗑

Health Insurance Portability and Accountability Act of 1996

HIPAA

🗑

Omnibus Consolidated and Emergency Supplemental Appropriations Act of 1999

OCESAA

🗑

Payment Error and Prevention Program

PEPP

🗑

Balanced Budget Refinement Act of 1999

BBRA

🗑

Medicare Prescription Drug, Improvement, and Modernization Act of 2003

MMA

🗑

False Claims Act

FCA

🗑

Tax Equity and Fiscal Responsibility Act of 1983`

TEFRA

🗑

The CMS-1500 claim form requires responses to standard questions pertaining to whether the patient's condition is related to:

An auto accident Secondary Insurance Employement

🗑

Which of the following is not an example of a managed care plan?

Consumer-directed health plan

🗑

According to the U.S. Census Bureau data from 2005, what percentage of people in the United States are covered by government plans (e.g., Medicare, Medicaid, TRICARE)

27%

🗑

The CPT manual is published by the:

American Medical Association

🗑

According to the Health Insurance Association of America, what is the largest area of health care fraud?

Misrepresenting diagnoses

🗑

If the insurance plan has a hold harmless clause it means:

the patient is not responsible for paying what the insurance plan denies

🗑

Regulated fraud associated with military contractors selling supplies and equipment to the Union Army.

False Claims Act

🗑

What organization is owned by hospital(s) and physician groups that obtain managed care plan contracts?

Physician-hospital organization

🗑

The first Blue Shield plan was founded in:

California

🗑

Title XVIII of the SSA of 1965

Medicare

🗑

Standards of laboratory testing

CLIA

🗑

Health care services to subscribers in a given geographical area for a fixed fee

HMO

🗑

Coverage for prolonged illnesses and injuries

Major Medical Insurance

🗑

Promotes correct coding methodologies

NCCI

🗑

Specified amount paid for each physician visit

Copay

🗑

Contract that protects from loss

Insurance

🗑

Forerunner of today's managed care plans

Prepaid health plans

🗑

Protection from occupational hazards in the workplace

OSHA

🗑

Weekly benefit amount divided into quarters

Base period

🗑

Title XIX of the SSA of 1965

Medicaid

🗑

Percentage of cost patient shares with the health plan

Coinsurance

🗑

Amount the patient is financially responsible for before an insurance policy provides payment

Deductible

🗑

Contractual right of a third-party payer to recover health care expenses from a liability party

Subrogation

🗑

Identification of disease and provision of care

Medical care

🗑

A plan offered either by a single insurance plan or as a joint venture by two or more insurance carriers, and which provides subscribers or employees with a choice of HMO, PPO, or traditional health plan is a:

A triple option plan Cafeteria plan Flexible benefit plan

🗑

Who requires physician offices to submit ICD-9-CM codes on CMS-1500 claim forms?

Medicare

🗑

Disability insurance provides the disabled person with financial assistance, but does not generally pay for:

Unemployment insurance benefits Medical services

🗑

A point of service plan (POS):

allows subscribers to choose between a network provider or out-of-network provider

🗑

Preventive services:

May result in the early detection of health problems Allow treatment options that are less dramatic and less expensive

🗑

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