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64 terms

Medical Insurance Final Review

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 Select. which one is not TRICARE options
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
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
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
Indian Health Service
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
Health insurance specialist review the patient record when assigning codes to
SOAP notes are writen in what format
The __ part of the note contains the chief complaint and patient's description of the presenting problems
The __ of the note contains documentation of measurable or objective observations made during the physical examination and diagnostic testing
The __part of the note is the statement of the physician's intended medical management of the case
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
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
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.
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
Some branches of the military that are covered under TRICARE include___
Air Force
How many regions are there in TRICARE
When a CHAMVA beneficiary also has Medicare coverage,___is always the secondary payer
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
___ & ___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