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Insurance Final

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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