Kinn's Chapter 15 & 18 Study Guide

If the ICD 10 codes and the CPT/HCPCS codes do not match the claim will not show what?

Medical necessity

The first step in filing a claim with a third party is what?

Obtaining accurate billing information from the patient

Which medicare plan required the patient to pay a monthly premium?

Part B

A provider that has a contract with the insurance company and agrees to rules and negotiations is called a what?

Participating provider

The medical assistant should always follow office ______ for claim review and signatures:

Policies

When should you verify the patient's eligibility for insurance coverage and collect patient information?

Prior to rendering medical services

What is precertification?

Process of determining if a procedure or service is covered by the insurance plan and what the reimbursement is for that procedure

What section of the claim form contains information on the patient and the insured?

Section 2

What is a deductible?

The amount of money a policy holder pays per claim before the insurance company will pay

What block is the assignment of benefits found in?

13

What block on the claim form is the insured's name found in?

4

Secondary health plan is located in which block?

9d

What is a copayment?

A set dollar amount that the policyholder must pay for each visit.

What methods can be used to verify a patient's eligibility for insurance?

Calling the provider services number on the back of the health insurance ID card and using provider web portal sponsored by the patient's health insurance company.

A payment method in which providers are paid for each individual enrolled in a plan, regardless of whether the person sees the provider that month, is called a ______ plan.

Capitation

What is coinsurance?

Certain percentage of the allowed amount that the policy holder is responsible for

The medical assistant should always verify what prior to the patient's appointment?

Eligibility, benefits, exclusions, and effective date of service

Know how to calculate insurance responsibility on payment of a claim.

Example Bill is for $500.00 insurance pays at 80% 500 x 0.80 = 400

A document sent by the insurance company to the provider and the patient explaining the allowed charge, the amount reimbursed for services, and the patient's financial responsibility is called what?

Explanation of benefits

Abuse is knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program. Fraud is an unintended action that results in an over payment to the healthcare provider.

False False

What is Medicaid?

Federal and state sponsored health insurance program for the medically indigent

What is TRICARE?

Health insurance designed for military dependents and retired military personnel

A review of individual cases by a committee to make sure that services are medically necessary is called a:

Utilization review

What does adjudicate mean?

To settle or determine judicially

What is electronic date interchange?

Transferring data back and forth between two or more entities