Chapter 13 SB

If a claimant decides to pursue an appeal with the state insurance commission, which of the following documents must be sent along with an explanation? (Select all that apply.) - All documents that relate to the initial claim determination - All documents that relate to the appeal process - Copies of the patient's medical record - Copies of the complete case file

- All documents that relate to the initial claim determination - All documents that relate to the appeal process - Copies of the complete case file

Which of the following questions are asked when performing the automated review check for utilization review? (Select all that apply.) - Has the provider overcharged for any appropriate services? - Are the hospital-based healthcare services appropriate? - Are there charges for services that are not medically necessary or that are over the frequency limits of the plan? - Are days and services authorized consistent with services and dates billed?

- Are the hospital-based healthcare services appropriate? - Are there charges for services that are not medically necessary or that are over the frequency limits of the plan? - Are days and services authorized consistent with services and dates billed?

If a claim is denied or downcoded for lack of medical necessity, which of the following would be the next actions to take? (Select all that apply.) - Bill the patient. - Write off the amount as a contractual adjustment. - Bill the insurance company. - Challenge the determination with an appeal.

- Bill the patient. - Write off the amount as a contractual adjustment. - Challenge the determination with an appeal.

Which of the following questions are typically asked when performing the automated review check to determine patient eligibility for benefits? - Does the patient have any dependents? - Has the claim been sent within the payer's time limits for filing claims? - Is the patient eligible for the services that are billed? - Are valid preauthorization or referral numbers present as required under the payer's policies?

- Has the claim been sent within the payer's time limits for filing claims? - Is the patient eligible for the services that are billed? - Are valid preauthorization or referral numbers present as required under the payer's policies?

Which of the following types of information are often located in separate sections on an RA? (Select all that apply.) - Header information - Totals - Claim information - Recipient information - Glossary

- Header information - Totals - Claim information - Glossary

To have claims processed as quickly as possible, medical insurance specialists must be familiar with which of the following payers' claim-processing procedures? - How to resubmit corrected claims that are denied because of missing or incorrect data - How to submit initial claims that are delayed because of missing or incorrect data - How to handle requests for additional documentation if required by the payer - Timetables for submitting corrected claims and for filing secondary claims

- How to submit initial claims that are delayed because of missing or incorrect data - How to handle requests for additional documentation if required by the payer - Timetables for submitting corrected claims and for filing secondary claims

The accounts receivable is made up of payments from which of the following? (Select all that apply.) - Money due from patients - Money due from vendors - Money due from the doctor - Money due from payers

- Money due from patients - Money due from payers

Which of the following are typical problems of denial management? (Select all that apply.) - Partially paid, denied, or downcoded claims - Rejected claims - Procedures not paid - Procedures totally paid

- Partially paid, denied, or downcoded claims - Rejected claims - Procedures not paid

To explain the determination to the provider of an adjustment on a claim, payers use a combination of which of the following codes? (Select all that apply.) - Remittance advice remark code - Claim adjustment reason code - Claim adjustment group code - Explanation of benefits remark code

- Remittance advice remark code - Claim adjustment reason code - Claim adjustment group code

What should the medical insurance specialist do when the payer rejects claims with errors or simple mistakes and transmits instructions to the provider to correct errors and/or omissions and to rebill the service? (Select all that apply.) - Submit a clean claim, if necessary, that the payer accepts for processing. - Respond as quickly as possible by supplying the correct information. - Call the insurance company and give them the correct information over the phone. - Wait for the insurance company to correct the information before rebilling.

- Submit a clean claim, if necessary, that the payer accepts for processing. - Respond as quickly as possible by supplying the correct information.

Which of the following are examples of overpayments on claims? (Select all that apply.) - The claim should have been denied or downcoded because the documentation did not support it. - The provider may have collected a primary payment from Medicare when another payer is primary. - The provider collected a payment from the primary payer. - The claim was paid twice.

- The claim should have been denied or downcoded because the documentation did not support it. - The provider may have collected a primary payment from Medicare when another payer is primary. - The claim was paid twice.

.If problems are identified in the automated review, what two things will happen to the claim? - The claim will be paid. - The claim will be suspended. - The claim will be set aside for development. - The claim will be accepted.

- The claim will be suspended. - The claim will be set aside for development.

Which of the following problems might be found in the initial processing of a claim? (Select all that apply.) - The patient is not the correct sex for a reported gender-specific procedure code. - The diagnosis code is missing or is not valid for the date of service. - The patient's name, plan identification number, or place of service code is wrong. - There is more than one diagnosis code for the procedure and the date of service.

- The patient is not the correct sex for a reported gender-specific procedure code. - The diagnosis code is missing or is not valid for the date of service. - The patient's name, plan identification number, or place of service code is wrong.

Postpayment reviews are used for which of the following? (Select all that apply.) - To uncover fraud and abuse - To build clinical information - To study treatments and outcomes - To verify the medical necessity of reported services - To eliminate postpayment reviews

- To uncover fraud and abuse - To build clinical information - To study treatments and outcomes - To verify the medical necessity of reported services

Postpayment reviews are used for which of the following? (Select all that apply.) - To eliminate postpayment reviews - To verify the medical necessity of reported services - To build clinical information - To uncover fraud and abuse - To study treatments and outcomes

- To verify the medical necessity of reported services - To build clinical information - To uncover fraud and abuse - To study treatments and outcomes

Which of the following are examples of payment and adjustment transactions that are entered in the practice management program? (Select all that apply.) - Total payment amount - Date of check - Payer name and type - Check or EFT number - Date of deposit

- Total payment amount - Payer name and type - Check or EFT number - Date of deposit

In which of the following situations is Medicare the primary payer? (Select all that apply.) - When an individual is retired and receiving coverage under a previous employer's group policy - When an individual is employed and is covered by the employer's group health plan - When an individual is enrolled in Part B but not Part A of the Medicare program - When an individual is working for an employer with twenty or fewer employees

- When an individual is retired and receiving coverage under a previous employer's group policy - When an individual is enrolled in Part B but not Part A of the Medicare program - When an individual is working for an employer with twenty or fewer employees

In which of the following situations is Medicare the secondary payer? (Select all that apply.) Multiple select question. - When an individual must pay premiums to receive Part A coverage - When an individual is working for an employer with twenty or fewer employees - When an individual over age sixty-five is covered by a spouse's employer's group health plan - When an individual is employed and is covered by the employer's group health plan

- When an individual over age sixty-five is covered by a spouse's employer's group health plan - When an individual is employed and is covered by the employer's group health plan

When does the practice not have to send a claim to the secondary payer? (Select all that apply.) - When the claim automatically crosses over - When the secondary payer handles the coordination of benefits transaction - When the claim is not a crossover - When the primary payer handles the coordination of benefits transaction

- When the claim automatically crosses over - When the primary payer handles the coordination of benefits transaction

When claims are sent to the medical review department to be reviewed by a claims examiner, the examiner may ask the provider for clinical documentation to check which of the following? (Select all that apply.) - Where the service took place - Whether at least three modifiers have been added to the CPT code - Whether the treatments were appropriate and a logical outcome of the facts and conditions that are shown in the medical record - Whether services provided were accurately reported - Whether patient payments are up-to-date

- Where the service took place - Whether the treatments were appropriate and a logical outcome of the facts and conditions that are shown in the medical record - Whether services provided were accurately reported

An adjustment on the RA means that the payer is paying a claim or a service line differently than billed. The adjustment may be that the item is which of the following? (Select all that apply.) Multiple select question. -Denied - Higher amount paid - Reduced amount paid - Less because a penalty is subtracted from the payment - Zero pay

-Denied - Reduced amount paid - Less because a penalty is subtracted from the payment - Zero pay

Claim adjustment reason codes are used to provide details about what? Multiple choice question. Allowed amounts Adjustments Payments Denials

Adjustments

Regulations mandated under the _____ as of January 1, 2014, require a trace number to appear on both the EFT and its ERA, so the documents are easy to match electronically. Medicare Act Centers for Affordable Care Act Affordable Care Act Payment Care Act

Affordable Care Act

When do some payers use online or automated telephone procedures or special forms to resubmit claims? Multiple choice question. To follow up before a claim has been resubmitted Before missing information has been supplied After missing information has been supplied To follow up after a claim has been resubmitted

After missing information has been supplied

What feature in a PMP automatically posts the payment data in the RA to the correct account? Multiple choice question. Adjudication Payment posting Reconciliation Autoposting

Autoposting

What is the next step to take when a patient has additional insurance coverage, after the primary payer's RA has been posted? Multiple choice question. Call the insurance company. Perform an audit. Bill the second payer. File an appeal.

Bill the second payer.

If a paper RA is received, the procedure is to use the _____ to bill the secondary health plan that covers the beneficiary. Multiple choice question. CMS-1500 ICD-10-CM UB 92 HIPAA 837P

CMS-1500

The secondary payer determines whether additional benefits are due under the policy's _____ provisions and sends payment with another RA to the billing provider. Multiple choice question. EOB COB PMP RA

COB

A(n) _____ lists claims that have been adjudicated within the payment cycle alphanumerically by the patient account number assigned by provider, alphabetically by client name, or numerically by the internal control number. Multiple choice question. CPT RA EOB PMP

CPT RA

What is the time period in which a health plan must process a claim? Multiple choice question. Prompt turnaround time Claim turnaround time Claim processing time Prompt pay time

Claim turnaround time

Many practices that receive RAs authorize the payer to deposit directly into the practice's bank account through a(n) _____. Multiple choice question. PMP CPT EFT EOB

EFT

The HIPAA X12 835 Health Care Payment and Remittance Advice (HIPAA 835) is the HIPAA-mandated electronic transaction for payment explanation. What is the document that the beneficiary receives? Multiple choice question. ERA PCP EOB RA

EOB

When the payer receives claims, what kind of response is issued to the sender showing that the transmission has been successful? Mail Email Paper Electronic

Electronic

The Fraud Enforcement and Recovery Act (FERA) of 2009 made major changes to which act by defining the act of keeping an overpayment from the federal government as fraud? Multiple choice question. False Claims Act (FCA) Fraud Claims Act Affordable Care Act Medicare Appeal Act

False Claims Act (FCA)

What government program provides insurance coverage for coal miners? Multiple choice question. Federal Black Lung Program Federal Brown Lung Program State Black Lung Program Medicare Black Lung Program

Federal Black Lung Program

What government program provides insurance coverage for coal miners? Multiple choice question. Federal Brown Lung Program Federal Black Lung Program Medicare Black Lung Program State Black Lung Program

Federal Black Lung Program

Which of the following are the basic steps of the general appeal process? (Select all that apply.) Multiple select question. Decision Grievance Appeal Complaint

Grievance Appeal Complaint

If Medicare is the secondary payer to one primary payer, the claim must be submitted using the _____ transaction unless the practice is excluded from electronic transaction rules. Multiple choice question. UB 92 ICD-10-CM HIPAA 837P CMS-1500

HIPAA 837P

What is the standard electronic transaction that obtains information on the current status of a claim during the adjudication process? HIPAA X12 276 Health Care Claim Status Response HIPAA 276/277 Health Care Claim Status Inquiry/Response HIPAA X12 277 Health Care Claim Status Inquiry HIPAA X12 276/277 Health Care Claim Status Inquiry/Response

HIPAA X12 276/277 Health Care Claim Status Inquiry/Response

Which section of an RA contains the payer name and address; provider name, address, and NPI; date of issue; and the check or electronic funds transfer transaction number? Multiple choice question. Claim information Glossary Totals Header information

Header information

In what situation is appealing a claim not necessary for Medicare-participating providers? If the claim was appealed and then paid If the claim was denied for major errors or omissions If the claim was denied for minor errors or omissions If the claim was paid even though there was an error

If the claim was denied for minor errors or omissions

What happens to the difference between the billed amount and the allowed amount unless it can be billed to the patient under the payer's rules? Multiple choice question. It is billed to the insurance. It is written off. It is used to reconcile the statement. It is appealed.

It is written off.

Which of the following explains Medicare payment decisions? Multiple choice question. Claim adjustment reason codes Claim adjustment group codes Medicare adjustment codes MOA remark codes

MOA remark codes

Benefits for a patient who has both Medicare and other coverage are coordinated under the rules of the _____ program. Multiple choice question. COB PCP MSP ACA

MSP

When completing a paper claim, who completes the claim form and sends it with the primary RA attached? Medical insurance specialist Primary insurance company Secondary payer Patient

Medical insurance specialist

To process the RA, the remittance data are reviewed and then posted where? Multiple choice question. PMP PCP EOB CPT

PMP

What do practices use to closely track the money that is owed for services rendered? Multiple choice question. Electronic health records Newspaper reports Prompt payment laws Practice management program

Practice management program

Who reviews the appropriate guidelines and required forms for the particular insurance carrier before starting an appeal and plans its actions according to the rules? Multiple choice question. Patient Insurance company Practice staff Defendant

Practice staff

What laws obligate state-licensed carriers to pay clean claims for both participating and nonparticipating providers within a certain time period or incur interest penalties, fines, and lawyers' fees? Multiple choice question. Claim turnaround laws Prompt-pay laws Prompt processing laws Claim payment laws

Prompt-pay laws

What summarizes the results of the payer's adjudication process? Multiple choice question. EOB PMP RA PCP

RA

When billing the secondary payer for noncrossover claims, the medical insurance specialist prepares an additional claim for the secondary payer and sends it with a copy of what? Multiple choice question. PMP RA EOB PCP

RA

Which of the following is used by payers to explain the payers' payment decisions? Multiple choice question. RARC MOA PARC CARC

RARC

When a payment is due for an approved claim, the payer sends which of the following to the provider along with the payment? Multiple choice question. Electronic remittance transmission Electronic EOB Explanation of benefits Remittance advice

Remittance advice

Who can the claimant contact with another appeal if the payer has rejected all the appeal levels on a claim? Federal insurance commission Local insurance commission County insurance commission State insurance commission

State insurance commission

The header information of an RA contains a place for "bulletin board" information, which is made up of notes for whom? Multiple choice question. The PMP The patient The provider The insurance company

The provider

How many formulas are used to calculate the amount of the patient's coinsurance that will be paid by Medicare under MSP? Multiple choice question. Five Four Two Three

Three

A(n) _____ is a process that can be used to challenge a payer's decision to deny, reduce, or otherwise downcode a claim. Multiple choice question. grievance review audit appeal

appeal

When a claim has been denied or payment reduced, an _____ may be filed with the payer for reconsideration, possibly reversing the nonpayment. appeal explanation adjustment audit

appeal

Postpayment _____ by payers may change the initial determination of a claim. Multiple choice question. denials renewals audits considerations

audits

Payers use _____ to provide details about adjustments. Multiple choice question. payer adjustment codes claim adjustment group codes RA remark codes claim adjustment reason codes

claim adjustment reason codes

The resource needed to match the payment to a claim on the RA is called the _____. Multiple choice question. RA control number insurance ID number EOB control number claim control number

claim control number

The person filing an appeal is the _____ or the appellant, whether that individual is a provider or a patient. Multiple choice question. defendant reviewer claimant appealer

claimant

Which of the following are the three formulas for the completion of MSP claims? - Higher allowed charge (either primary payer or Medicare) minus payment made on the claim - Lower allowed charge (either primary payer or Medicare) minus payment made on the claim - What Medicare would pay (80 percent of Medicare allowed charge) - Primary payer's allowed charge minus payment made on the claim

completion of MSP claims? - Higher allowed charge (either primary payer or Medicare) minus payment made on the claim - What Medicare would pay (80 percent of Medicare allowed charge) - Primary payer's allowed charge minus payment made on the claim

For _____ claims, the specialist reports a two-digit insurance type code under the MSP program. Multiple choice question. secondary electronic paper manual

electronic

If a medical practice believes that an insurance company has treated it unfairly, it has the right to file a(n) _____ with the state insurance commission. Multiple choice question. audit appeal lawsuit grievance

grievance

From the payer's point of view, _____ are improper or excessive payments resulting from billing errors for which the provider owes refunds. Multiple choice question. overpayments prepayments payments postpayments

overpayments

A grievance is a complaint filed by a practice with the state insurance commission against a _____. Multiple choice question. payee provider patient payer

payer

A(n) _____ audit might be conducted to check the documentation of the provider's cases or, in some cases, to check for fraudulent practices. Multiple choice question. prepayment postpayment Medicare overpayment

postpayment

A(n) _____ audit might be conducted to check the documentation of the provider's cases or, in some cases, to check for fraudulent practices. prepayment overpayment postpayment Medicare

postpayment

If a patient is covered by both Medicare and Medicaid, Medicare is _____. secondary tertiary primary unapproved

primary

If an individual under age sixty-five is disabled and they or family member is not actively employed, Medicare is the _____ payer. Multiple choice question. secondary approved tertiary primary

primary

The process of _____ means making sure that the totals on the RA check out mathematically. Multiple choice question. appeals reconciliation autoposting auditing

reconciliation

If an individual receives treatment for a job-related injury or illness, Medicare coverage (and private insurance) is _____ to workers' compensation coverage. Multiple choice question. primary secondary approved tertiary

secondary

If an individual receives treatment for a job-related injury or illness, Medicare coverage (and private insurance) is _____ to workers' compensation coverage. Multiple choice question. secondary approved tertiary primary

secondary

If an individual under age sixty-five is disabled and is covered by an employer group health plan (which may be held by the individual, a spouse, or another family member), Medicare is the _____ payer. unapproved primary tertiary secondary

secondary

The claim that is sent to Medicare is automatically crossed over to Medicaid for _____ payment. crossover tertiary secondary primary

secondary

When TRICARE is the secondary payer, _____ item numbers on a paper claim are filled in differently than when TRICARE is the primary payer. Multiple choice question. four three five six

six

Whether sent electronically or in a paper format, the basic information in the remittance advice transaction is _____. similar the same not the same different

the same

FERA encourages qui tam lawsuits, which extend the _____ protection to cover both contractors and agents of an entity, in addition to employees. patient whistle-blower provider insurance company

whistle-blower