Insurance Study Guide Chapter 3

A provider who directly treats a patient is called a(n):

Direct provider

When a provider asks a health plan for approval of a service, the response is known as the:

X12 278

Which of the following is used to send necessary data to payers for a claim?

X12 837

Which of the following is another common term for encounter forms?

Superbills | Routing slips | Charge slips (All of these are correct)

Patients may have fill-in-the-gap insurance called:

Supplemental

What information does RTCA allow the practice to view?

The amount the health plan will pay and amount patient will owe

If an employed patient has coverage under two insurance plans, one from a current employer and one from a previous employer, the primary plan is:

The current employer's plan

What type of information is not found on an insurance card?

The date the policyholder first paid a premium

If an employed patient has coverage under two insurance plans, one the employer's plan and the other a government plan, the primary plan is:

The employer's plan

Which of the following information is gathered on the patient information form?

The patient's personal and insurance information

If a patient has coverage under two insurance plans, one under which the patient is the policyholder and one under which the patient is a dependent, the primary plan is:

The patient's plan

Identify the information that is not typically included on an encounter form.

The patient's plan benefits

Assignment of benefits authorizes:

The physician to file claims for a patient and receive direct payments from the payer

Charging TOS payments depends on:

The provision of their health plan and practice's financial policy

Determine which of the following entities would be given a referral number.

The referred physician

What information must be documented in the patient's financial record when communicating with payers?

The representative name, date and outcome

If a retired patient with Medicare also has coverage under a working spouse's plan, the primary plan is:

The spouse's plan

In recording a patient's name when sending it to a payer, what version of their name should be used?

Their name as it is shown on the insurance card

A new patient is defined as one who has NOT seen the provider within the last:

Three years

An established patient is defined as one who has seen the provider within the last:

Three years

Identify a situation in which insurance is checked after an encounter.

A medical emergency occurs

What are the procedures that ensure billable services are recorded and reported for payment called?

Charge capture

Which HIPAA transaction is used to send information from a primary payer to a secondary payer?

Coordination of Benefits

What does COB stand for in medical insurance terms?

Coordination of benefits

What provision explains how insurance policies will pay if more than one policy applies?

Coordination of benefits

What type of charges do practices routinely collect at the time of service?

Copays, noncovered, and self-pay patients

Financial policies usually contain the following information:

Credit policy, insufficient funds payment policy, and insurance information

What type of provider is required to have patients sign an acknowledgment?

Direct provider

So that everyone in the practice can follow the financial policy it should be:

Displayed on the wall of the reception area or included in new patient information packet

Describe what should be done when incorrect or conflicting data are discovered on encounter forms.

Double-check the documentation and communicate with physician

What does a provider complete during or just after a patient's visit to summarize their billing information?

Encounter form

Which of these documents will the patient not complete?

Encounter form

If a patient authorizes a provider to accept assignment, what can the provider now do on their behalf?

File claims for the patient and receive payments directly from the payer

You are working at a practice and have been asked to document some payer communications. Determine where the communications should be recorded.

Financial record

Where is an assignment of benefits statement filed?

Patient medical records and patient billing records

A patient presents for an appointment, and you must locate the information about their health plan. Determine where this information should be located.

Patient's information form and insurance card

If the practice accepts credit and debit cards it must:

Pay a fee to a credit card company

Pick the type of use of PHI that a practice would employ to submit claims on behalf of a patient.

Payment

When should the insurance specialist update the encounter form?

Periodically when codes change

A patient with no previous balance presents for an encounter and wants to know what their bill will be. Calculate the patient's estimated balance if they will receive a service worth $127 and have a $15 copayment.

$112

If a provider has agreed to accept assignment, he/she will:

Accept what the insurance allows

The document patients sign to signify that they have read and understood how the provider will protect their PHI is the:

Acknowledgment of Receipt of Notice of Privacy Practices

What Medicare form is used to show charges to patients for noncovered services?

Advance Beneficiary Notice

For assigned claims, the payment for services rendered is expected:

After the patient receives a statement

For unassigned claims, the payment for services rendered is expected:

At the time of service

Examine the types of information below and determine which type is NOT important to collect from a new patient.

Availability for future appointments

Under what rule is a child's primary coverage determined based upon which parent's day of birth is earlier in the calendar year?

Birthday rule

Another term for prior authorization is:

Certification

Who typically documents the patient's vital signs?

Clinical medical assistant

You are working in a practice and a patient arrives for an appointment on November 20, 2018; the patient last visited the practice on March 5, 2014, and is scheduled to see the same physician. Determine what you should ask the patient to do upon arrival.

Complete many forms before their first encounter with the provider

Which HIPAA transaction is used to check patients' insurance coverage?

Eligibility for a Health Plan

What type of questions should be asked to physicians regarding billing and coding issues?

Essential only

Who should the front desk at a medical office ask about whether any of their pertinent personal or insurance information has changed?

Established patients

The practice's rules for payment for medical services are found in their:

Financial policy

Under what rule is a child's primary coverage under the father's plan when both parents have coverage?

Gender rule

If a patient has coverage under two insurance plans, the primary plan is the one that?

Has been in effect for the patient the longest

A patient has just seen the physician and received two different covered services that normally require copayments. Determine how the payment should be handled.

If the health plan permits multiple copayments, both should be collected

A provider such as a facility who does not have face-to-face interaction with a patient is called a(n):

Indirect provider

The terms "subscriber" and "guarantor" have the same meaning as:

Insured

A "self-pay" patient is one who:

Is uninsured

Under a coordination of benefits provision, what about the secondary payer is required to be reported?

It is only required to be reported to the primary insurance if you have assignment of benefits

What means are available for completing an encounter form?

Laptop computers, tablet PCs, and PDAs

What is set up in the practice management program when a patient's chief complaint is different than the one for a previous encounter?

New case

Patients who elect to pay a higher copayment, greater coinsurance, or both, are most likely visiting a:

NonPAR

Patients will have the same chart number when:

None of these; chart numbers are unique

Identify the person/entity that must authorize providers to release a patient's PHI for TPO purposes.

None of these; they do not need authorization

NonPAR stands for:

Nonparticipating

In what format does an encounter form come?

Paper and electronic

A patient arrives for an appointment and you need to locate his insurance information. You would use which of the following documents to find it?

Patient information form

In what order are benefits typically determined when the parents do not have joint custody arrangements?

Plan of the custodial parent, plan of spouse of custodial parent, plan of parent without custody

What can be used to verify insurance company information?

Portal

Identify the means by which practices can be sure that all visits have been entered in the practice management program.

Prenumbering

Identify the best time during which to begin collecting patient information.

Preregistration process

The first health plan to pay when more than one plan is in effect is called the:

Primary insurance

What do payers issue when they approve a service?

Prior authorization number

When the practice can get answers quickly from insurance plans, it will benefit from?

Quicker payment for services

What is the process when you can create a claim while the patient is being checked out and receive an immediate response from the payer?

RTCA

What process is used to quickly generate the amount a patient owes?

Real-time claims adjudication

You are working at a practice, and need to get prior approval from a payer. Which of the following HIPAA transaction would you use to do so?

Referral Certification and Authorization

You are working in a practice and a patient arrives for an appointment on February 8, 2016; the patient last visited the practice on May 14th, 2013 and is scheduled to see the same physician. Determine what you should ask the patient to do upon arrival.

Review and update the information that is on file about them

After one health plan has paid on a claim, which insurance makes the next payment, if applicable?

Secondary insurance

Determine how a policyholder can authorize physicians to submit claims on their behalf and receive payments directly from payers.

Signing and dating an assignment of benefits statement

What type of information is included in a patient's social history?

Smoking, alcohol use, and exercise habits

Another term for the insured is:

Subscriber

Sometimes the use of a third payer is necessary after two health plans have made payments on a claim. This type of insurance is known as:

Tertiary insurance

What does an Acknowledgment of Receipt of Notice of Privacy Practices state?

That the patient understands how the provider intends to protect their rights to privacy under HIPAA

An RTCA generates:

The actual amount the patient will owe

What should be verified when someone requests PHI for TPO purposes?

The identity of the person and person's authority to access PHI

Identify the factor that does not determine a patient's copayment.

The length of time the patient has been seeing the practice

Determine by which of the following means a practice may receive a "self-refer:"

The patient comes for specialty care without a referral number when one is required

What type of number is assigned to a HIPAA 270 electronic transaction?

Trace number

Pick the type of use of PHI that a practice would employ to discuss a patient's case with another provider.

Treatment

The initial step in establishing financial responsibility is to:

Verify the payer's rules for the medical necessity of the planned service

What is another name for the HIPAA Eligibility for a Health Plan transaction?

X12 270/271

What must patients who are members of CDHPs do before their health plan makes a payment?

Meet a large deductible

A patient's insurance card usually shows:

Member identification number

Eligibility for Medicaid may change as quickly as:

Monthly

Select the most likely destination for a patient being sent by a referring physician.

Another physician

Under Medicare, what must a provider receive before they are permitted to collect a deductible or any other payment?

Data on how the claim is going to be paid

Pick the type of use of PHI that a practice would employ to train their staff to improve the quality of their health care

Health care operations