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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
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.
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 Standards, TRICARE Prime, TRICARE Extra, TRICARE Select. which one is not TRICARE options
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
____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
A ___contracts with a third-party payer and accepts whatever the plan pays for procedures or services performed.
Generate a separate __ record and __ record for each patient to maintain each type of information
___ is the insurance plan responsible for paying health care insurance claims first
The health insurance specialist employed in a physicain's office assigns ICD-9-CM codes to
diagnoses, signs, & sympyoms documented by the provider
Removal of a cast applied by another physician, pesonal history of breast cancer, & exposure to tuberculosis are all example of what type of codes?
Of the following which is/are sections of the CPT manual
medicine, pathology & laboratory , radiology
Medicare is always a secondary payer when a Medicare beneficiary also has coverage from which of the following groups
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
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
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
Medicaid is jointly funded by the __ & __governments to assist states in proving adequate medical care to qualified individuals
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.
Any provider who accepts a Medicaid patient must accept the Medicaid-determined payment as
payment in full
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
___ & ___laws require employers to maintain workers' compensation coverage for employees for work-related illnesses & injuries
Office of Workers' Compensation Program (OWCP) provides
wage replacement benefits
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
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
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