Chapter 4 Medical Insurance

Claims adjudication involves making a determination about ____ charges which is the maximum amount the payer will permit for each procedure or service, according to the patient's policy.

allowed

Coordination of benefits (COB) is a provision in _____health insurance policies intended to keep multiple insurers from paying benefits covered by other policies.

group

Which person is responsible for paying the charges?

guarantor

Which is the financial record source document used by health care providers and other personnel in a physician's office setting to record treated diagnoses and services rendered to the patient during the current visit?

superbill

A claims attachment is ______documentation associated with a health care claim or patient encounter

supporting

The patient underwent office surgery on March 18, and the third-party payer determined the allowed change to be $1,480. The patient paid the 20 percent coinsurance at the time of the office surgery. The physician and patient each received a check for $1,184, and the patient signed her check over to the physician. The overpayment was _________ and the physician must reimburse the third-party payer.

$1,184

Which is an electronic format supported for health care claims transactions?

ANSI ASC X12-837

Which involves comparing the claim to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures performed or services provided are covered benefits?

claims adjudication

Which involves sorting claims upon submission to collect and verify information about the patient and provider?

claims processing

Which is the electronic or manual transmission of claims data to payers or clearinghouses for processing?

claims submission

Electronic claims are submitted directly to the payer after being checked for accuracy by billing software of a health care clearinghouse, which results in a ______claim that contains all required data elements needed to process and pay the claim.

clean

Which claims are filed according to year and insurance company and include those for which all processing, including appeals, has been completed?

closed claims

A nonparticipating provider (nonPAR) is an out-of-network provider who does not contract with insurance plan, and patients who elect to receive care from non-PARs will incur higher out of pocket expenses. The patient ____ expected to pay the difference between the insurance payment and the provider's fee.

is usually

A remittance advice submitted to the provider electronically is called an electronic remittance advice (ERA), and __________

it contains identical information to the information on a paper-based remittance advice

An appeal is documented as a(n) _____why a claim should be reconsidered for payment.

letter signed by the provider explaining

When applying the birthday rule, if policyholders have identical birthdays, the policy in effect the ______is considered primary.

longest

When a child lives with both parents, and each parent subscribes to a different health insurance plan, the primary and secondary policies are determined by applying the birthday rule. The individual who holds the primary policy for dependent children is the spouse whose birth ________

month and day occur earlier in the calendar year

A child is listed as a dependent on both his father's and his mother's group insurance policies. The father's birth date is March 20, 1977, and the mother's birth date is March 6, 1979. Which policy is primary?

mother's policy

Which claims are organized by month and insurance company after submission to the payer, but for which processing is not complete?

open claims

Health insurance plans may include a(n) _____provision, which means that when the patient has reached that limit for the year, appropriate patient reimbursement to the provider is determined.

out-of-pocket payment

Which is a computerized permanent record of all financial transactions between the patient and the practice?

patient account record

Which is a manual permanent record of all financial transactions between the patient and the practice?

patient ledger

Which is the insurance plan responsible for paying health care insurance claims first?

primary insurance

Which claims are organized by year and are generated for providers who do not accept assignment?

unassigned claims

Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization, are called _____services.

unauthorized

Dr. Jones is a nonparticipating provider (nonPAR) for the ABC Health Insurance Plan. Anne Smith is treated by Dr. Jones in the office for which $100 fee is charged. Given the information in the table located below, calculate the nonPAR provider write-off amount. nonPAR provider fee $100 nonPAR allowable charge $90 Patient copayment $18 Insurance payament $72 nonPAR provider write-off amount______

$10

Dr. Smith is a participating provider (PAR) for the ABC Health Insurance Plan. Mary Talley is treated by Dr. Smith in the office for which a $100 fee is charged. Given the information in the table located below, calculate the PAR provider write-off moment.

$20

Sally Simmons is a patient of Dr. Tyler's. She received preventive services for her annual physical examination on May 17. The third-party payer determined the allowed charge for preventive services to be $100, for which the payer reimbursed the physician 80 percent of that amount. Sally is responsible for paying the remaining 20 percent directly to the physician. Thus, the physician will receive a check in the amount of _____from the payer, and the patient will pay _____to the physician.

$80, $20

Covered entities are required to use mandated national standards when conducting any of the defined transactions covered under HIPAA. Which is an example of a covered entity?

ERISA-covered health benefit plans

When selecting a clearinghouse, providers may also want to determine whether it's accredited by the____

Electronic Healthcare Network Accreditation Commission

Which means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim?

accept assignment

Which best assists providers in the overall collection of appropriate reimbursement for services rendered?

accounts receivable management

A participating provider (PAR) contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed. This means that PARs_____ allowed to bill patients for the difference between the contracted rate and their normal fee.

are not

A pre-existing condition is any medical condition that was diagnosed and/or treated within a specified period of time _______the enrollee's effective date of coverage.

before

A policyholder or ______is the person in whose name the insurance policy is issued.

beneficiary

Which is the financial record source document used by health care providers and other personnel in a hospital outpatient setting to select codes for treated diagnoses and services rendered to the patient during the current visit?

chargemaster

Which is the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid?

coinsurance

The claim is also checked against the ______, which is an abstract of all recent claims filed on each patient and helps determine whether the patient is receiving concurrent care for the same condition by more than one provider.

common data file

Which is the fixed amount the patient pays each time he or she receives health care services?

copayment

The computer-to-computer transfer of data between providers and third-party payers (or providers and health care clearinghouses) in a data format agreed upon by sending and receiving parties is called electronic_________.

data interchange

The manual daily accounts receivable journal is also known as the _______, and it is a chronologic summary of all transactions posted to individual patient ledgers accounts on a specific date.

day sheet

Which is the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits?

deductible

Any procedures or service reported on the claim that is not included on the master benefit list is a non covered benefit and will result in claims______

denial

Providers have the option of arranging for _______, which means that payers deposit reimbursement for health care services to the provider's account electronically.

electronic funds transfer

Clearinghouses process claims in an electronic flat file format, which requires conversion of CMS-1500 claims data to a standard format. Providers can also use software to convert claims to an electronic flat file format, also known as(n) ____, which is a series of fixed-length records (e.g., 25 spaces for patient's name) submitted to payers as a bill for health care services.

electronic media claim

Which is considered a financial source document from which an insurance claim is generated?

encounter form

Which is the financial record source document used by health care providers and other personnel to record treated diagnoses and services rendered to the patient during the current visit?

encounter form

A clearinghouse that involves value-added vendors, such as banks, in the processing of claims is called a value-added______ to improve efficiency and reduce expenses.

network

Medicare calls its remittance advice a(n)_________.

provider remittance notice

Secondary insurance is the insurance plan that is billed after the primary insurance plan has paid its contracted amount and the provider's office has received a(n) ______from the primary payer.

remittance advice