Marcy's Insurance Final
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121 terms
Terms | Definitions |
|---|---|
 When a Medicare beneficiary has employer supplemental coverage, Medicare refers to these plans as | MSP. |
| The time limit within which a TRICARE inpatient claim must be filed is within | 1 year from a patient's discharge from an inpatient facility |
| What is the protocol to follow on receiving a request for an attending physician's statement from an insurance company on a patient who has applied for health insurance? | Request a fee from the insurance company before sending the attending physician's statement. |
| What level of education is generally required for one who seeks employment as an insurance coder? | Completion of an accredited program for coding certification |
| The medically needy aged | require help in meeting costs of medical care |
| What does bundling mean | Grouping codes that are related to a procedure |
| The most important function of a practice management system is | accounts receivable. |
| An organization that gives members freedom of choice among physicians and hospitals and provides a higher level of benefits if the providers listed on the plan are used is called a/an | preferred provider organization (PPO). |
| Confidential information includes | everything that is heard about a patient. B) everything that is read about a patient. C) everything that is seen regarding a patient |
| A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as | CC. |
| An insurance claim form that contains no staples or highlighted areas and on which the bar code area has not been deformed is called | a physically clean claim. |
| The average amount of accounts receivable should be | 1.5 to 2 times the charges for 1 month of services |
| The largest section in the CPT book is the | surgery section. |
| The Part B Medicare annual deductible is | 135 |
| The letters preceding the number on the patient's Medicare identification card indicate | railroad retiree |
| Basic Maternal and Child Health Program (MCHP) provisions offered in all states include | children with handicap needs who require orthopedic treatment or plastic surgery |
| When a physician sees a patient more than is medically necessary, it is called | churning. |
| Privileged information is related to the treatment and progress of patients. | true |
| Office visits may be grouped on the insurance claim form if each visit | is consecutive, uses the same procedure code, and results in the same fee |
| In a bankruptcy case, most medical bills are considered | unsecured debt. |
| What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care? | Foundation for medical care |
| The official American Hospital Association policy states that "abbreviations should be totally eliminated from the more vital sections of the record, such as the" | final diagnosis. B) operative notes. C) discharge summaries |
| Exceptions to the right of privacy rule include | gunshot wound cases |
| What is the name of the federal act that prohibits discrimination in all areas of granting credit? | Equal Credit Opportunity Act |
| How should blocks be treated on an OCR CMS-1500 claim form that do not need any information | Leave the block blank |
| Medicaid is administered by the | state government with partial federal funding |
| The diagnosis listed first in submitting insurance claims for patients seen in a physician's office is the | primary diagnosis |
| When a remittance advice (RA) is received from Medicare, the insurance billing specialist should | post each patient's name and the amount of payment on the day sheet and the patient's ledger card |
| The physician who is responsible for coordinating and managing all of the health care for the TRICARE Prime patient is referred to as a/an | PCM. |
| What is the best response when telephoning a patient about an insurance matter and the patient's voice mail is reached? | Use care in the choice of words when leaving the message |
| Who may accept a subpoena? | The prospective witness B) An authorized person |
| The Medicaid program was a direct result of | a law passed by Congress in 1950. |
| Part B of Medicare covers | diagnostic tests. |
| In the Medicare program, there is mandatory assignment for | clinical laboratory tests |
| What is the correct procedure to collect a copayment on a managed care plan? | Collect the copayment when the patient arrives for the office visit |
| 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 date of service |
| Accounts that are 90 days or older should not exceed | 15% to 18% of the total accounts receivable |
| An insurance claim submitted with errors is referred to as | a dirty claim |
| What action could happen if an employee knowingly submits a fraudulent Medicare or Medicaid claim at the direction of the employer and subsequently the medical practice is audited? | The employee and the employer could be brought into litigation by the state or federal government |
| Confidential information includes | everything that is heard about a patient. B) everything that is read about a patient. C) everything that is seen regarding a patient |
| Insurance claims transmitted electronically are usually paid in | 2 weeks or less |
| Confidential information includes | everything that is heard about a patient. B) everything that is read about a patient. C) everything that is seen regarding a patient |
| A clearinghouse is a/an | entity that receives transmission of insurance claims, separates the claims, and sends each one electronically to the correct insurance payer |
| If a payment problem develops with an insurance company and the company ignores claims and exceeds time limits to pay a claim, it is prudent to contact the | state insurance commissioner |
| Part B of Medicare covers | diagnostic tests |
| OCR guidelines for the CMS-1500 claim form state | it should not be photocopied because it cannot be scanned |
| Back-up copies of office records should be stored | away from the office |
| Which type of bankruptcy is considered "wage earner's bankruptcy | Chapter 13 |
| A concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor that is the reason for the encounter is abbreviated as | CC |
| Part A of Medicare covers | hospice care. |
| What action could happen if an employee knowingly submits a fraudulent Medicare or Medicaid claim at the direction of the employer and subsequently the medical practice is audited? | The employee and the employer could be brought into litigation by the state or federal government |
| How should blocks be treated on an OCR CMS-1500 claim form that do not need any information? | Leave the block blank |
| How many levels of review exist for TRICARE appeal procedures | Three |
| The time limit for submitting a Medicare claim is | the end of the calendar year following the fiscal year in which services were performed |
| What is the name of an organization of physicians sponsored by a state or local medical association that is concerned with the development and delivery of medical services and the cost of health care | Foundation for medical care |
| The medically needy aged | require help in meeting costs of medical care |
| What should be done if an insurance company denies a service stating it was not medically necessary and the physician believes it was? | Rebill with a letter of explanation from the physician |
| The Medicaid program was a direct result of | a law passed by Congress in 1950 |
| A medical practice has a policy of billing only for charges in excess of $50. When the medical assistant requests a $45 payment for the office visit, the patient states, "Just bill me." How should the medical assistant respond | State the office policy and ask for the full fee. |
| How should an entry in a patient's medical record be corrected? | Cross out the incorrect entry, substitute the correct information, date and initial the entry |
| What is the correct procedure to collect a copayment on a managed care plan? | Collect the copayment when the patient arrives for the office visit |
| When a service is rendered that is not listed in the CPT codebook | use a code with a description stating "unlisted." |
| Back-and-forth communication between user and computer that occurs during online real time is called | interactive transaction |
| A code system used for managing patient electronic health records, information, indexing, and billing laboratory problems is called | SNOMED. |
| Which of the following cases should NOT use fax transmission? | Transmission of documents relating to information on sexually transmitted diseases B) Any routine transmission of patient information C) Transmission of documents relating to alcohol treatment |
| In a bankruptcy case, most medical bills are considered | unsecured debt |
| Under the prospective payment system (PPS), hospitals treating Medicare patients are reimbursed according to | preestablished rates for each type of illness treated based on diagnosis. |
| In the Medicare program, there is mandatory assignment for | clinical laboratory tests |
| 70. The HCPCS national alphanumeric codes are referred to as | Level II codes |
| When a Medicare beneficiary has employer supplemental coverage, Medicare refers to these plans as | MSP |
| What is the name of the federal act that prohibits discrimination in all areas of granting credit? | Equal Credit Opportunity Act |
| When insurance carriers do not pay claims in a timely manner, what effect does this have on the medical practice | Decreased cash flow |
| Exceptions to the right of privacy rule include | gunshot wound cases |
| The total number of levels of redetermination that exist in the Medicare program is | five |
| Who may accept a subpoena | The prospective witness B) An authorized person |
| An explanation of benefits document for a patient under the Medicare program is referred to as the | Medicare remittance advice document |
| In what case should a V code be used | Sterilization |
| Medicare is a | federal health insurance program |
| The patient is likely to be the most cooperative in furnishing details necessary for a complete registration process | before any services are provided |
| The Medicaid service for prevention, early detection, and treatment for welfare children is known as | EPSDT |
| What should you do if an insurance carrier requests information about another insurance carrier? | Provide the information |
| Basic Maternal and Child Health Program (MCHP) provisions offered in all states include | children with handicap needs who require orthopedic treatment or plastic surgery |
| A group of insurance claims sent at the same time from one facility is known as a | A group of insurance claims sent at the same time from one facility is known as a |
| If a physician accepts Medicaid patients, the physician must accept | the Medicaid-allowed amount |
| Medicaid eligibility must always be checked for the | month of service. B) type of service |
| The frequency of Pap tests that may be billed for a Medicare patient who is low risk is | once every 24 months |
| What is the correct response when a relative calls asking about a patient? | Have the physician return the telephone call |
| Medical etiquette refers to | consideration for others |
| The reason for a fee reduction must be documented in the patient's | medical record. |
| Reasons for documentation are | defense of a professional liability claim. B) insurance carriers require accurate documentation that supports procedure and diagnostic codes |
| Payments to hospitals for Medicare services are classified according to | DRGs |
| Referral of a patient recommended by one specialist to another specialist is known as | tertiary care. |
| Organizations handling claims from hospitals, nursing facilities, intermediate care facilities, long-term care facilities, and home health agencies are called | fiscal intermediaries |
| When a Medicare carrier transmits a Medigap claim electronically to the Medigap carrier, it is referred to as a/an | crossover claim |
| Medicare Part A is run by | the Centers for Medicare and Medicaid Services |
| When is the principal diagnosis applicable | Inpatient hospital coding |
| The key to substantiating procedure and diagnostic code selections for proper reimbursement is | supporting documentation in the health record |
| A new patient is one who | ) has not received any professional services from the physician within the past 3 years |
| The TRICARE fiscal year extends from | October 1 to September 30 |
| The CPT publication is updated and revised | annually |
| When a medical practice has its own computer and transmits claims electronically directly to the insurance carrier, this system is known as | carrier-direct. |
| State Children's Health Insurance Programs (SCHIPs) | operate with federal grant support under Title V of the Social Security Act |
| What is the consequence when a medical practice does not use diagnostic codes? | It affects the physician's level of reimbursement for inpatient claims. B) Claims can be denied. C) Fines or penalties can be levied |
| The time limit within which a TRICARE outpatient claim must be filed is | within 1 year from the date a service is provided |
| A participating physician with the Medicare plan agrees to accept | 80% of the Medicare-approved charge |
| What should be done to inform a new patient of office fees and payment policies? | Send a patient information brochure. B) Send a confirmation letter. C) Discuss fees and policies at the time of the initial contact |
| What level of education is generally required for one who seeks employment as an insurance coder | Completion of an accredited program for coding certification |
| A medical report is a | permanent legal document, part of the health record |
| A state-based group of doctors working under government guidelines reviewing cases for hospital admission and discharge is known as a: | QIO |
| Medicare Part A benefit period ends when a patient | has not been a bed patient in any hospital or nursing facility for 60 consecutive days |
| When a remittance advice (RA) is received from Medicare, the insurance billing specialist should | post each patient's name and the amount of payment on the day sheet and the patient's ledger card |
| The CMS-1500 claim form is divided into which of the following major sections? | Patient and physician information |
| Medicare provides a one-time baseline mammographic examination for women ages 35 to 39 and preventive mammogram screenings for women 40 years or older | once a year |
| A Medicare prepayment screen | identifies claims to review for medical necessity. B) monitors the number of times given procedures can be billed during a specific time frame |
| An example of a technical error on an insurance claim is | duplicate dates of service. B) transposed numbers. C) missing place of service code |
| If a check is received from Medicare and it is obvious that it is an overpayment, the insurance billing specialist should | deposit the check and then write to Medicare to notify them of the overpayment |
| An established patient is one who | has previously received professional services from a physician or another physician of the same specialty who belongs to the group practice within the past 3 years |
| An insurance claim submitted with errors is referred to as | a dirty claim |
| The diagnosis listed first in submitting insurance claims for patients seen in a physician's office is the | primary diagnosis |
| The employer's identification number is assigned by | the Internal Revenue Service |
| OSHA stands for | Occupational Safety and Health Administration |
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