Medical Insurance Final Review

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a claims examiner employed by a third-party payer reviews health-related claims to determine whether the charges are reasonable and for

medical neccessity

what involves linking every procedure or service code reported on the claim to a condition code that justifies the necessity of performing that procedure or service.

medical necessity

what does CPT stands for

Current Procedural Terminology

A successful health insurance specialist should have which of the following characteristics

Attention to details
strong sense of ethics
ability to work independently

health insurance is available to

individuals who particpate in individual (personal) health plans
participants of prepaid health plan
individuals who particpate in group (employer-sponsored health plans

Health care coverage available through employers and others organizations in which employers usually pay part or all of the premium costs is

group health insurance

TRICARE includes three plans options.

TRICARE Standards, TRICARE Prime, TRICARE Extra

TRICARE Standards, TRICARE Prime, TRICARE Extra, TRICARE Select. which one is not TRICARE options

TRICARE Select

abbrevations' OCR stands for

optrical character reader

This is created when a number of people are grouped for insurance purposes and the cost of health care coverage is determined by employees' health status, age, sex, & occupation

Risk pool

____is a voluntary processnthat a health care facility or organization (e.g., hospital, manage care plan) undergoes to demonstrate that it has met standards beyond those required by law

Accreditation

the development of a (an) ___begins when the patient contacts a health care provider's office and schedules an appointment

insurance claim

the CMS-1500 is used to report

professional services and technical services

The __ is the person responsible for paying the charges

guarantor

A ___contracts with a third-party payer and accepts whatever the plan pays for procedures or services performed.

participating provider

Generate a separate __ record and __ record for each patient to maintain each type of information

financial, medical

___ is the insurance plan responsible for paying health care insurance claims first

Primary insurance

The health insurance specialist employed in a physicain's office assigns ICD-9-CM codes to

diagnoses, signs, & sympyoms documented by the provider

What volume of the ICD-9-CM contains the Index to Diseases

Volume 2

Removal of a cast applied by another physician, pesonal history of breast cancer, & exposure to tuberculosis are all example of what type of codes?

V codes

the bull's-eye symbol indicates

a procedure includes moderate (conscious) sedation

Of the following which is/are sections of the CPT manual

medicine, pathology & laboratory , radiology

Which of the following is a federal health care program

CHAMPVA
Indian Health Service
Medicaid

Medicare is always a secondary payer when a Medicare beneficiary also has coverage from which of the following groups

workers' compensation
veterans administrative benefits
automobile medical or no-fault insurance

Procedures and services submitted on a claim must be linked to the__ that justifies the need for the service or procedure

ICD-9-CM code

How many diagnosis code may be reported on each CMS-1500 claims

Up to 4

The procedure or service provided is linked with the __that provided medical necessity for performing the procedure or service

diagnosis/condition

Health insurance specialist review the patient record when assigning codes to

diagnoses
procedures
services

SOAP notes are writen in what format

Outline

The __ part of the note contains the chief complaint and patient's description of the presenting problems

Subjective

The __ of the note contains documentation of measurable or objective observations made during the physical examination and diagnostic testing

Objective

The __part of the note is the statement of the physician's intended medical management of the case

Plan

Optical scanning paper claims uses a scanner to convert printed or handwritten characters into text that can be viewed by

an optical character reader

Patients sign Block 13 of the CMS-1500 claim to instruct the payer to directly reimburse the provider, this is an

acceptance of benefits

When coding physician office and outpatient claims. do you always report a code for proable, suspicious for, or rule out

no

When filing out the CMS-1500 claim form for the policyholder's name should appear as

Last name-First name-Middle initial(separated with commas)

When entering Signature on File on Block 12 the appropriate date to enter would be

no date is necessary, leave blank

Although commercial claims completion instructions are recognized worldwide, it is important to check with each payer to

routine check for updates
determine if they require alternate information to be entered on the claim
discover any new implementations in claims completion requirements

Blue Cross plans were initiated in 1929 & originally provided coverage for

Hospitals bills

Blue sheild was created in 1938 & originally covered

physician services

Which of the following is attached when completing secondary claims

A remittance advice

All Medicare beneficiaries can also obtain a supplement insurance policy called

Medigap

Medicaid is jointly funded by the __ & __governments to assist states in proving adequate medical care to qualified individuals

federal, state

What would be covered under Medicaid

Categorically needy
Medically needy
Special groups

TANF was previously known as

Aid to Family with Dependent Children

What does the acronym TANF stand for

Temporary Assistance for Needy Families

the portion of the Medicaid program paid by the federal government is known as the

Federal Medical Assistance Percentage

The federal government reimburses states___of the cost of services provided through facilities of the Indian Health Service.

100%

Medicaid is always either the

primary payer or payer of the last resort

Any provider who accepts a Medicaid patient must accept the Medicaid-determined payment as

payment in full

TRICARE Standard was preivous known as

CHAMPUS

Some branches of the military that are covered under TRICARE include___

Army
Navy
Air Force

How many regions are there in TRICARE

4

When a CHAMVA beneficiary also has Medicare coverage,___is always the secondary payer

CHAMPVA

Individuals eligible foe TRICARE Prime include

active duty military personal
family members of active duty sponsors
retirees & their family members who are under 65 years of age

Checks for eligibility reporting system

DEERS

___ & ___laws require employers to maintain workers' compensation coverage for employees for work-related illnesses & injuries

Federal, state

Office of Workers' Compensation Program (OWCP) provides

wage replacement benefits
medical treatment
vocation rehabilitation

The Division of Federal Employees' Compensation Act processes

medical expenses & compensation benefits to injured workers and survivors

Which program covers workers under contract with the U.S. goverment for defense projects outside the continental United States

Longshore and Harbor Workers' Compensation Program

How are survivor benefits calculated

According to the employee's earning capacity at the time of illness or injury

insurance covers the medical expenses of individuals and groups; and premiums and benefits vary according to the type of plan offered

Commercial Insurance

Traditional healthcare coverage subsidized by employers & other organizations (e.g., labor unions, rural and consumer health cooperatives) whereby part or all of premium costs are paid for and/or discounted group rates are offered to eligible individuals

group health insurance

MTF is the acronym for

Military Treatment Facilities

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