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The Health Claim Form, also known as the universal claim form, is often called or referred to as?

CMS-1500

A claim that is submitted to the insurance carrier via a dial-up modem is referred to as?

Electronic Claim

When the patient is insured by two companies, the coverage is sometimes referred to as ?

dual coverage

A husband and wife both have insurance through their employers, and each has added the spouse to their insurance plans for coverage. If the wife is seen for treatment, then her plan is considered?

Primary

The abbreviation MCO stands for?

managed care organization

The law states that an employer employing ___ or more persons may offer the services of an HMO clinic as an alternative health treatment plan for employees.

25

A primary care physician who controls patient access to specialists is called a?

gatekeeper

Benefits under the HMO Act fall under two categories: ________ health services and supplemental health services.

Basic

the process called _____ is an evaluation of the quality and efficiency of services rendered by a practicing physician within the specialty group.

Peer Review

UR is the abbreviation for?

utilization review

When a managed care plan requires the primary care physician to seek approval before referring a patient to a specialist, it is called obtaining?

pre-authorization

When a capitated patient's services go over a certain amount an the physician can begin asking the patient to pay (fee for service), this arrangment is provided in a _______ section of the managed care contract or agreement.

stop loss

Medicare provides insurance for people ____ years of age or older who are retired on social security.

65

Medicare outpatient coverage is referred to as Part _____?

B

The Civil Monetary Penalties Law carries a sanction for a penalty of up to ________ for each item or service wrongfully listed in a payment request to Medicare or Medicaid.

2500

A Medicare nonparticipating physician may bill no more than the Medicare _____.

Limiting Charge

The Medicare HCPCS coding system has ____ levels.

two

When a Medicare patient authorization is on file, the abbreviation ____ may be used on the CMS-1500 claim form.

SOF

An NPI number issued to a provider by CMS is the acronym for?

National Provider Identification

What does ESRD stand for?

end stage renal disease

What does TEFRA stand for?

Tax, Eniquite, and Fiscal Responsibility Act

What type of coverage does a Medi-Medi patient have?

Medicare and Medicaid

When Medicare payments are posted to a separate day sheet, what should the day sheet payment total agree with?

deposit slip

If you receive a request from the insurance company on an EOB or a letter, asking you to abstract medical information from a patient's medical record, what should you do?

send only a copy of the information requested

On a CMS-1500 claim form if you have blocks that do not need information. What do you do?

leave the block blank

Kaiser Permanente's medical plan is a closed panel program. Which means?

it limits the patient's choice of personal physicians

what was created and gave the federal government authorization to help in the HMO development?

Health Maintenance Act of 1973

How does an HMO physician receive payment for the services provided?

Prepaid Health plan

Referral, a patient that is recommended by one specialist to another specialist is known as?

tertiary care

What type of organization is Medicare Part A run by?

the Center for Medicare and Medicaid Services

What does Medicare Part B Cover?

diagnostic tests

How often does Medicare provide a mammogram exam for women ages 35 to 39 and preventive mammograms for women 40 years or older?

once a year

What is the time frame we can bill for a pap test done on a low risk Medicare patient?

once every 24 months

Medigap insurance is a supplemental coverage designed to cover?

the deductible not covered under Medicare

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?

Crossover claim

What should an insurance billing specialist do, if they received a check from Medicare and it is obvious that it is an overpayment?

Deposit the check and then write to Medicare to notify them of the overpayment

An insurance claim submitted with errors is referred to as?

A dirty claim

What does the acronym OCR stand for?

optical character recognition

What are the OCR guidelines for the CMS-1500 claim form?

it should not be photocopied because it cannot be scanned.

To conform to CMS-1500 OCR guidelines you need to?

all the above: do not fold insurance claim forms when mailing, do not use symbols with data on insurance claim forms, and do not strike over errors when making a correction on an insurance claim form.

What does Medicare Part A cover?

hospice care

What does a participating physician with Medicare agrees to accept?

80% of the Medicare-approved charge

What does a Medicare prepayment screen do?

both a and b: identify claims to review for medical necessity, and monitors the number of times given procedures can be billed during 1 year.

Medicaid is always billed first.

false

program of medical assistance for certain low income is medicaid.

true

appeals time limit is usally

30-60 days

There are 3 aid programs for medicare patients who?

all of the above: have difficulty paying copay & deductibles, have low income, and difficulty paying premiums

PT account must be cash pay until retroactive eligibility is established.

true

It is the Dr's responsibility to verify eligibility on date of service.

true

What form does patient sign if services are disallowed?

waiver of liability form.

Claims must be filed within one year of date of service.

true

photocopy both sides of card and retain in patients chart.

true

Filing electronic is the most efficient way to file claims

true

if pt has tricare for life services, are billed to Medicaid 1st then tricare.

false

a Par & non-par dr can bill tricare 115% of allowable charges.

false

Dr who conducts medically legal evaluations of injured workers?

all of the above: independent medical evaluator, qualified medical evaluator, and agreed medical evaluator.

a compromise & release is a settlement between WC & injured employee.

true

IT is very important to keep wc ins chart separate from private ins chart.

true

work status is?

estimated time temporary disability will end.

What is a progress report?

information of current status of patient

When billing out of state wc claim you don't have to follow the rules & fee schedule fo the state claim originated.

false

A medicare claim that contains complete, necessary information but is illogical or incorrect.

invalid claim

an insurance claim held in suspense due to reveiw or other reason.

pending claim.

an insurance claim that is submitted within the program or policy time limit and correctly completed.

clean claim.

an insurance claim that is submitted with errors.

dirty claim.

an insurance claim that requires investigation and needs further clarification?

rejected claim

an insurance claim that is submitted on paper, including optically scanned claims?

paper claim

an insurance claim that is submitted via a dial-up modem or direct data entry.

electronic claim

A medicare claim that is missing required information.

incomplete claim.

Refer to an updated diagnostic codebook and reveiw the patient record.

diagnostic code is missing.

obtain data from patient during the first office visit on which company is the primary insurer.

the insurance claim was submitted to the secondary instead of the primary insurer.

verify and submit valid modifiers with the correct procedure codes for which they are valid.

incorrect modifier.

check for Sr., Jr., correct birthdate, and verify the insured.

Patient's name and insured's name are entered as the same when the patient is a dependent.

Verify with patient's medical record that all dates of service are listed and accurate.

duplicate dates of service listed

refer to the current procedure codebooks and verify the coding system used by the insurance company.

Procedure code is invalid

submit all attachments with patients name and insurance id number.

operative report is missing from the insurance claim

total all charges on each claim, recheck the math, and verify amounts with patient account

total amounts do not equal itemized amounts charged

proofread numbers carefully from source documents

the patient's insurance number is incorrect

verify that the place of service is correct for the submitted procedure code (s) and fill in correct service code.

missing place of service code.

Max dollar amount to be considered for payment of services or procedure.

medicaid allowance

bill sent to insurance company

CMS-1500 claim

patient must meet payment that is above the rate that medicaid pays for medical service.

share of cost

dollar amount of payment that is above the rate that medicaid pays for medical service

coinsurance

small fixed amount paid to dr at time of service

co-payment

service not covered by medicaid

disallowed

amount of money must be paid before benefits begin

deductible

remittance advice explanation of benefits

RA/EOB

Individual who qualifies for tricare

beneficiary

details the payment of the claim

summary payment voucher

civilian health care services plan

tricare standard

voluntary health maintenance org plan

tricare prime

active duty service member

sponsor

supplementary plan for service retirees

tricare for life

a pro type of option plan

tricare extra

defense enrollment eligibility reporting system

deers

involves a minor injury in which the pt is seen by dr but is still able to work

non-disability

authorizes dr to treat employee

medical service order

abnormal condition disorder caused by exposure to environmental factors

occupational illness

pt unable to perform duties of occupation for a specific range of time

temporary disability

medical report detailing injury

first report

patient unable to return to their former occupation

permanent disability

written agreement of payment recognized in court

liens

occupational safety & health administration act

OSHA

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