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The Claims Process - Set 3

NCCT Reviewer
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peer review
If an appeal for a legitimate claim is unsuccessful, the physician may request a __________?

a) different tracer
b) refund
c) new carrier arrangement
d) peer review
present a military ID
It is important for a TRICARE patients to always ___________?

a) present a military ID
b) submit a claim on-line
c) register with Social Services
d) file a CMS-1500
out of plan
If a nonmember physician treats an HMO patient, the services are termed __________?

a) provisional
b) approved
c) out of plan
d) improper
Excessive overtime
Which of the following practices would NOT be noted by utilization review __________?

a) Churning
b) Turfing
c) Excessive overtime
d) Buffing
type of payment agreement where the physician is paid per person whether seen or not
Capitation refers to a _______________?

a) type of payment agreement where the physician is paid per person whether seen or not
b) type of posting done manually in the physicians office
c) fee for service agreement where a dollor amount is set for each service or precedure
d) tax paid by the physician to the Internal Revenue Service
makes no promise to cover a full fee
An indemnity benefit contract ___________?

a) offers physician participation
b) makes no promise to cover a full fee
c) is a service contract
d) is offered through Medicare
reduce the incidence of surgery
Second opinion programs _________?

a) refer data to clearinghouse
b) are billed electronically
c) benefit referring physicians
d) reduce the incidence of surgery
age of the patient
Itemized bills to Blue Cross and Blue Shield must contain the following EXCEPT _________?

a) professional status of the physician
b) age of the patient
c) date of service
d) type of serice
federal guidelines
Each state designs its own Medicaid program within ________?

a) local guidelines
b) federal guidelines
c) international guidelines
d) AMA guidelines
65 years old business executives
All but which of the following may be covered by Medicaid __________?

a) 65 years old business executives
b) Patients who cannot see
c) Patients with disabilities
d) 65 years old patients
Military dependents
In the medicaid program, which one of the following groups is NOT usually considered categorically needy __________?

a) QMBs
b) AFDC-releated groups
c) SSI cash recipients
d) Military dependents
Cosmeticsurgery
Which of the following is NOT covered by Medicaid _________?

a) Birth control
b) Cosmetic surgery
c) X-rays
d) Immunizations
a true emergency
Prior approval for certain services in the Medicaid program is necessary EXCEPT for ________?

a) transportation
b) a true emergency
c) hearing aids
d) prosthetic devices
Contact lens to change the color of the eyes
All but which of the following might be covered by Medicaid _________?

a) Inpatient care for a digestive disorder
b) Hemodialysis fir a kidney patient
c) Surgery (hysterectomy) for dysfunctional uterine bleeding
d) Conract lens to change the color of the eyes
reciprocity
If a patient requires care while out of state, most states offer Medicaid __________?

a) training
b) education
c) reciprocity
d) refunds
rejected
if a Medicaid bill is submitted after the time limit it will most likely be __________?

a) rejected
b) reviewed
c) paid
d) ignored
month
Medicaid eligibility for participants should be verified every ________?

a) month
b) three months
c) six months
d) year
secondary carrier
If a person elegible for Medicaid has other insurance coverage, Medicaid is always the ____________?

a) first insurance billed
b) responsible third party liability carrier
c) primary carrier
d) secondary carrier
preschool children
Medicare is a federal health insurance program for the following categories of people EXCEPT ________?

a) people 65 years or older
b) preschool children
c) blind individuals
d) disabled widows
day a patient enters the hospital
For Medicare inpatient services, a benefit period begins the ___________?

a) day a patient enters the hosptial
b) first day the physician sees the patient in the office for the illness or injury
c) 3rd day of a hospital stay
d) first day home from the hospital
purchasing medical equipment
A patient might submit his own Medicare claim when __________?

a) the hospital is in a rural location
b) the time liit has passed
c) purchasing medical equipment
d) the physician is too busy
a witnessshould sign the form
When an illiterate patient cannot sign a Medicaid form _______?

a) s/he should be referred to a literacy program
b) a supervisor shoudl be notified
c) a withness should be sign the form
d) care is denied