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42 Cards in this Set
- Front
- Back
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Who is responsible for updating the CMS-1500? |
CMS (Center for Medicare and Medicaid Services) |
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Describe the CMS-1500 form. |
-Has 33 boxes/blocks -It is OCR (Optical Character Recognition) in red ink -Only printed in English. |
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What is the most common format? |
Java. |
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What font works best with OCR? |
Mono-spaced font. |
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Does the CMS-1500 allow any punctuation? |
No |
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Do offices that contract with Medicare have to file claims electronically? |
Yes, unless they have a waiver. |
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What do you need in order to complete a CMS form? |
-Patient information form -Insurance card -Health record |
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What is a ledger card? |
It is where a patient's charges and payments are recorded in. |
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What is direct data entry? |
Submitting claims directly to the insurance company. |
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What is a clean claim? |
A claim with no errors or omissions. |
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What happened during the last revision of the CMS-1500? |
It updated NPI (National Provider Identifier). |
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What is a 9 digit tax ID? |
EIM (Employee Identification Number) |
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What is on the CMS form? |
Top half: -Patient demographics
Bottom Half: -Contains physician supplier information |
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What is your responsibility? |
To obtain maximum reimbursement. |
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What are the names for the forms used to do billing? |
Encounter form, super bill, and charge slip. |
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Which blocks in the CMS-1500 contain patient information? |
Blocks 1 - 13 |
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What is the most common cause for claim rejections? |
Accept of assignment/signature in block 12 is missing. |
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Which form of claims has a faster rate of reimbursement? |
Electronic. |
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Which form of claims has a slower rate of reimbursement? |
Paper file/hard copies. |
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When is an attachment necessary when submitting a claim form? |
When an unlisted procedure is coded. |
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What is IPA? |
An HMO provided by out-patient networks. |
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Name two types of insurance. |
-Fee-for-Service (FFS) -Indemnity. |
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What a lifetime insurance cap? |
When a FFS policy sets limits for what they will pay. |
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What is a PAR provider? |
Physician that is in contract with an insurance company. |
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What is NCQA? |
Non-profit organization called "The Watchdogs." They oversee the quality of managed care. |
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What are two organizations that self-insurance policies hire to manage and pay claims? |
-ERSA -ASO |
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What do FFS plans have? |
-Premiums -Deductibles -Co-insurance |
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What is a referral? |
A request of a health care provider to be evaluated by a specialist. |
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What is self-insurance? |
When an employer is responsible for the cost of medical services. |
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What is a consultation? |
When a patient is sent to another provider for an opinion. |
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What is a co-payment? |
Small fee that a patient must pay before service. |
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How do most Americans obtain insurance? |
Through employers, so it is a group plan. |
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Name the three types of insurance. |
-HMO (Health Maintenance Organization) -EPO/POS (Exclusive Provider Organization/Point of Service) -PPO (Prefered Provider Organization |
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What is a grievance? |
A formal complaint letter. |
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What happens during a utilization review? |
Reduces in-patient and out-patient services. |
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What is name of the largest Medicare claims processor (Fiscal Intermediary)? |
Blue System. |
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What do you call patients enrolled in managed care programs? |
Enrollees. |
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What is the meaning of adjudication? |
To review. |
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What happens after adjudication? |
An EOB (Explanation of Benefits) is submitted. |
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What do all HMO recipient need? |
PCP (Primary Care Provider) aka "Gate Keeper." |
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What is a multi-speciality practice in a same complex where patients work? |
Staff model. |
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Do patients with PPOs require a PCP? |
No. |
