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42 Cards in this Set

  • Front
  • Back

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

assignment of benefits

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

Medicare Summary Notice

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


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.)

$450, patient

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

flat file format

Which is considered a covered entity?

private-sector payers that process electronic claims

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

open claim.

An electronic claim is submitted using______as its transmission media

magnetic tape

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

claims attachment

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

coordination of benefits

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


Which of the following steps would occur first?

Health insurance specialist completes electronic or paper-based claim

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


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

noncovered benefit

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?

common data file

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


Which of the following steps would occur first?
Clearinghouse transmits claims data to payers

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

participating provider

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?

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

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


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

Truth in Lending Act

Which protects information collected by consumer reporting agencies?

Fair Credit Reporting Act

Which is the best way to prevent delinquent claims?

Verify health plan identification information on all patients.

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

The delinquent claims are resolved directly with the payer

Which is an example of supporting documentation?

operative report

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

special report

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?


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

improve the efficiency and effectiveness of the health care system.

Electronic claims are

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

Patients can be billed for

noncovered procedures

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

Not paid by the third-party payer

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


The life cycle of an insurance claim is initiated when the

Health insurance specialist completes the CMS-1500 claim

Which form is considered the financial source document?

superbill or encounter form

Another name for the patient account record is the patient


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

Day sheet

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

Identifying information about all patients except the requesting patient is removed

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

Fair Debt Collection Practices Act

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


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

Coordination of benefits

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

Value-added network

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

Common data file