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The Health Claim Form, also known as the universal claim form, is often called or referred to as?
A claim that is submitted to the insurance carrier via a dial-up modem is referred to as?
When the patient is insured by two companies, the coverage is sometimes referred to as ?
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?
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.
Benefits under the HMO Act fall under two categories: ________ health services and supplemental health services.
the process called _____ is an evaluation of the quality and efficiency of services rendered by a practicing physician within the specialty group.
When a managed care plan requires the primary care physician to seek approval before referring a patient to a specialist, it is called obtaining?
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.
Medicare provides insurance for people ____ years of age or older who are retired on social security.
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.
When a Medicare patient authorization is on file, the abbreviation ____ may be used on the CMS-1500 claim form.
When Medicare payments are posted to a separate day sheet, what should the day sheet payment total agree with?
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
Referral, a patient that is recommended by one specialist to another specialist is known as?
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?
When a medicare carrier transmits a medigap claim electronically to the Medigap carrier, it is referred to as a?
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
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 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.
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
Dr who conducts medically legal evaluations of injured workers?
all of the above: independent medical evaluator, qualified medical evaluator, and agreed medical evaluator.
When billing out of state wc claim you don't have to follow the rules & fee schedule fo the state claim originated.
A medicare claim that contains complete, necessary information but is illogical or incorrect.
an insurance claim that is submitted within the program or policy time limit and correctly completed.
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.
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
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.
patient must meet payment that is above the rate that medicaid pays for medical service.
share of cost
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