Mod-D Chp-4

Front 1

Which means that the patient and/or insured has authorized the payer to reimburse the provider directly?

Back 1

assignment of benefits

Front 2

Providers who do not accept assignment of Medicare benefits do not receive information included on the_____, which is sent to the patient.

Back 2

Medicare Summary Notice

Front 3

The transmission of claims data to payers or clearinghouses is called claims

Back 3

submission

Front 4

A patient received services on April 5, totaling $1,000. He paid a $90 coinsurance at the time services were rendered. (The payer required the patient to pay a 20 percent coinsurance of the reasonable charge at the time services were provided.) The physician accepted assignment, and the insurance company established the reasonable charge as $450. On July 1, the provider received $360 from the insurance company. On August 1, the patient received a check from the insurance company in the amount of $450. The overpayment was_____, and the_____must reimburse the insurance company. (Remember! Coinsurance is the percentage of costs a patient shares with the health plan.)

Back 4

$450, patient

Front 5

A series of fixed-length records submitted to payers to bill for health care services is an electronic

Back 5

flat file format

Front 6

Which is considered a covered entity?

Back 6

private-sector payers that process electronic claims

Front 7

A claim that is rejected because of an error or omission is considered a(n)

Back 7

open claim.

Front 8

An electronic claim is submitted using______as its transmission media

Back 8

magnetic tape

Front 9

Which supporting documentation is associated with submission of an insurance claim?

Back 9

claims attachment

Front 10

Which is a group health insurance policy provision that prevents multiple payers from reimbursing benefits covered by other policies?

Back 10

coordination of benefits

Front 11

The sorting of claims upon submission to collect and verify information about the patient and provider is called claims

Back 11

processing.

Front 12

Which of the following steps would occur first?

Back 12

Health insurance specialist completes electronic or paper-based claim

Front 13

Comparing the claim to payer edits and the patient's health plan benefits is part of claims

Back 13

adjudication

Front 14

Which describes any procedure or service reported on a claim that is not included on the payer's master benefit list?

Back 14

noncovered benefit

Front 15

Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider?

Back 15

common data file

Front 16

Which is the fixed amount patients pay each time they receive health care services?

Back 16

copayment

Front 17

Which of the following steps would occur first?

Back 17

Clearinghouse transmits claims data to payers

Front 18

Which must accept whatever a payer reimburses for procedures or services performed?

Back 18

participating provider

Front 19

Which is an interpretation of the birthday rule regarding two group health insurance policies when the parents of a child covered on both policies are married to each other and live in the same household?

Back 19

The parent whose birth month and day occurs earlier in the calendar year is the primary policyholder

Front 20

Which is the financial record source document usually generated by a hospital?

Back 20

chargemaster

Front 21

Which requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions?

Back 21

Truth in Lending Act

Front 22

Which protects information collected by consumer reporting agencies?

Back 22

Fair Credit Reporting Act

Front 23

Which is the best way to prevent delinquent claims?

Back 23

Verify health plan identification information on all patients.

Front 24

Which is a characteristic of delinquent commercial claims awaiting payer reimbursement?

Back 24

The delinquent claims are resolved directly with the payer

Front 25

Which is an example of supporting documentation?

Back 25

operative report

Front 26

Supporting documentation that is attached to the CMS-1500 is either copied from the patients chat or developed. The letter is referred to

Back 26

special report

Front 27

Which claim status is assigned by the payer to allow the provider to correct errors or omissions on the claim and resubmit for payment consideration?

Back 27

Pending

Front 28

The intent of mandating HIPAAs national standards for electronic transactions was to

Back 28

improve the efficiency and effectiveness of the health care system.

Front 29

Electronic claims are

Back 29

checked for accuracy by billing software programs or a health care clearing house.

Front 30

Patients can be billed for

Back 30

noncovered procedures

Front 31

If the claim was denied because the service is not covered by the payer, the claim is.

Back 31

Not paid by the third-party payer

Front 32

The person in whose name the insurance policy is issued is the

Back 32

Policyholder.

Front 33

The life cycle of an insurance claim is initiated when the

Back 33

Health insurance specialist completes the CMS-1500 claim

Front 34

Which form is considered the financial source document?

Back 34

superbill or encounter form

Front 35

Another name for the patient account record is the patient

Back 35

Ledger

Front 36

A chronological summary of all transactions posted to individual patient account on a specific day is recorded on a(n)

Back 36

Day sheet

Front 37

What special handling is required if a patient requests a copy of the remittance advice (RA) that contains information about multiple patients?

Back 37

Identifying information about all patients except the requesting patient is removed

Front 38

Which federal law protects consumers against harassing or threatening phone calls from collectors?

Back 38

Fair Debt Collection Practices Act

Front 39

The time period between the point at which a claim is submitted and when the claim is paid is called the ,_______, period.

Back 39

Aging

Front 40

The provision in group health insurance policies that specifies in what sequence coverage will be provided when more than one policy covers the claim is

Back 40

Coordination of benefits

Front 41

A clearinghouse that coordinates with other entities to provide additional services during the processing of claims is a

Back 41

Value-added network

Front 42

To determine if a patient is receiving concurrent care for the same condition by more than one provider, the payer will check the claim against the

Back 42

Common data file