NCCT Claims Process

To determine whether a claim is delinquent, which of the following reports should the insurance and coding specialist generate? A. aging analysis B. patient analysis C. reimbursement analysis D. practice analysis

A aging analysis

A patient has made a payment towards his balance. Where should the insurance and coding specialist enter this payment? A. the ledger card B. the claim form C. the EOB D. the fee schedule

A the ledger card

Which of the following steps are appropriate to reconcile the day's financial transactions? (Select the three (3) correct answers.) A. Close out batches and add the balances. B. Post payments prior to bank deposit. C. Post copays after closing the batch. D. Issue receipts for all services rendered E. Run an audit trail.

A, B, D Close out batches and add the balances., Post payments prior to bank deposit., Issue receipts for all services rendered.

Which of the following is required information from the encounter form necessary for insurance reimbursement? (Select the three (3) correct answers.) A. date of service B. procedure codes C. physician's signature D. HCPCS codes E. authorization number

A, B, D date of service, procedure codes, HCPCS codes An encounter form is used for each patient visit. It is usually made specifically for that practice and includes common codes that the providers use. The providers then check off the codes as the patient's visit progresses. A date of service is used on this form, since it is expected that a patient will have many of these in his chart (from previous dates of service). A medical biller or coder will use the data from the encounter form to fill out portions of the claim form. A physician's signature is not required on an encounter form. An authorization number is also not included on an encounter form, as it should usually be prepared prior to a visit.

Which of the following should the insurance and coding specialist verify upon receiving an encounter form? (Select the three (3) correct answers.) A. doctor assessment B. date of service C. authorization number D. provided service E. patient balance

A, B, D doctor assessment, date of service, provided service

Which of the following are required, daily reconciliations in the physician office? (Select the three (3) correct answers.) A. EOB B. patient payments C. trial balances D. AR days E. AR balance

A, B, E EOB, patient payments, AR balance Daily reconciliation is a compilation of money owed and money received, including past due balances. For the daily reconciliation, all of the EOBs are needed, the patient payments received on that day, as well as the AR balance.

Which of the following data elements are required on a CMS 1500 form? (Select the three (3) correct answers.) A. date of service B. physician's billing address C. chief complaint D. payer ID E. patient's date of birth

A, B, E date of service, physician's billing address, patient's date of birth

Which of the following are factors in negotiating fee structures? (Select the three (3) correct answers.) A. how difficult it is for the provider to do the procedure B. involves the amount of overhead expenses for the procedure C. the relative risk that the procedure presents to the patient and provider D. the year's conversion factor E. fee based payment method

A,B, C how difficult it is for the provider to do the procedure, involves the amount of overhead expenses for the procedure, the relative risk that the procedure presents to the patient and provider There are many factors that are used in negotiating fee structures, which can raise or lower the allowed amount of a service. The difficulty level, the office overhead expenses, the risk of the procedure, the demographics of the place of service, and how common the procedure is can all affect the fee structure.

Which of the following requires a patient's signature for the medical facility/provider to be paid by the carrier? A. SOF B. ABN C. NPP D. RA

A. SOF SOF stands for "Signature on File".

The Assignment of Benefits form is used to allow the insurance company to A. pay the provider directly. B. pay the beneficiary directly. C. pay for the services provided. D. bill other insurance companies.

A. pay the provider directly. When a patient sees a new physician, one form that is filled out as part of the new patient paperwork is an Assignment of Benefits form. This form states that the patient is allowing the insurance company to pay the provider directly.

In order to determine if a claim is delinquent, which of the following reports must be generated? A. daily balance report B. A/R aging report C. analysis report D. batch report

B A/R aging report The A/R aging report is a report of all delinquent patient accounts. It includes how long the accounts have been delinquent and how much money is owed. A daily balance report is generated to show the money generated in a day. A batch report shows all of the encounters that have been billed out, in the groups in which they have been entered. An analysis report is a very broad term that can mean many different things in the healthcare world. Almost any data that can be formatted into a report can be called an analysis.

On a CMS-1500 form, which of the following fields does not have to be filed out for every patient? A. DOS B. LMP C. DOB D. POS

B LMP The LMP (last menstrual period) section of the CMS-1500 form will not be filled out for every patient. It will only be filled out for female patients who are pregnant, have recently been pregnant, or are experiencing medical issues with their reproductive system. The DOS (date of service), DOB (date of birth), and POS (place of service) must be filled out on every claim form, for every patient.

Which of the following is the definition of capitation payments? A. an RVS based payment B. a fixed, monthly payment C. a fee-for-service payment D. a prospective payment system

B a fixed, monthly payment

The physician requests the amount of monies unpaid on all accounts. The insurance and coding specialist should run the report for A. insurance carrier adjustments. B. accounts receivable aging. C. practice analysis. D. denial.

B accounts receivable aging.

Which of the following reports shows in detail the invoices that are overdue for payment? A. financial summary B. aging report C. accounts receivable D. managed care analysis

B aging report

The multipurpose billing forms should be reviewed and updated to include new or revised codes A. quarterly. B. annually. C. bi-monthly. D. monthly.

B annually. Codes can be added, deleted, or revised once a year, which means that billing forms should be updated annually to reflect the new changes, effective January 1st.

Patient A/R aging reports relieve staff of time-consuming activities such as A. tracking office expenditures. B. counting dollar amounts in outstanding accounts. C. preparing office income analysis. D. completing insurance claims forms.

B counting dollar amounts in outstanding accounts.

The Patient Information section of an encounter form contains A. diagnosis codes. B. date of service. C. physician's signature. D. treatment codes.

B date of service.

Office fees are set by the A. Centers for Medicare and Medicaid Services (CMS). B. physician. C. guarantor. D. third party payers.

B physician.

Which of the following ledgers should the insurance and coding specialist use to calculate cash, credit cards, and checks received from all patients during the business day? A. total charges B. total receipts C. total adjustments D. EOB

B total receipts The day's total receipts should be used to calculate all the payments for the day. Charges and adjustments are not payments. An EOB is a document sent from the insurance carrier and is not a payment.

Fee schedules are maintained and updated annually because fees should reflect which of the following? (Select the three (3) correct answers.) A. experience the providers have within their specialties. B. revenue necessary to maintain the financial stability of the practice. C. any new, deleted, or revised CPT® codes. D. changes to any insurance carrier policies regarding allowable amounts. E. type of services the provider delivers.

B, C, D revenue necessary to maintain the financial stability of the practice., any new, deleted, or revised CPT® codes., changes to any insurance carrier policies regarding allowable amounts. Fee schedules are maintained and updated annually to reflect many different aspects that also change annually, such as coding updates, utilities and costs of operating the practice, and any cost updates that the insurance carriers may inflict.

Which of the following signed documents should the insurance and coding specialist obtain from all new patients? (Select the three (3) correct answers.) A. insurance eligibility B. HIPAA acknowledgement C. financial responsibility D. advance beneficiary notice E. assignment of benefits

B, C, E HIPAA acknowledgement, financial responsibility, assignment of benefits

Which of the following are common reasons for a claim to be rejected by a primary payer? (Select the three (3) correct answers.) A. On the CMS 1500 form, Block 29, Amount Paid, is blank. B. Insurance ID number is incorrect. C. Tertiary insurance information is missing. D. Dates of service do not match charges. E. Diagnosis codes are not linked to procedures.

B, D, E Insurance ID number is incorrect., Dates of service do not match charges., Diagnosis codes are not linked to procedures. A claim can be rejected for many reasons. Some examples of claim rejection by the insurance carrier are: the insurance ID number is incorrect, the dates of service are incorrect, the diagnosis codes are not linked to the procedures, the physician information is missing, or the secondary insurance information is missing. It is allowable for the "Amount Paid" space to be left blank. There is no space on a CMS-1500 form for a tertiary (3rd) payer.

Box 13 on the CMS-1500 form stating, "Signature on File", is allowing which of the following? A. Primary Policy Holder B. Accept Assignment C. Assignment of Benefits D. Information about Third-Party Liability

C Assignment of Benefits

When completing the CMS 1500 form, where should the patient's secondary policy number be placed? A. Block 11 B. Block 1a C. Block 9a D. Block 9

C Block 9a

Which of the following is documented on a patient's ledger card once payment is received? A. CPT® codes B. ICD codes C. any credits D. balance due date

C any credits A ledger card is a running account of a patient's total financial account. It is like a check book, because it should show any money that has been paid, any money that is owed, or any money that has been credited, along with the dates of the transactions. Due dates are not recorded on the ledger card, only financial situations that have already happened are recorded, not what is expected to happen in the future. Codes are not used on this form

The insurance and coding specialist is required to post monthly payments from the insurance company that has a certain number of subscribers. A set dollar amount is received for each patient's services whether they were seen or not. Which of the following is this process is called? A. copay B. co-insurance C. capitation D. fee for services

C capitation

Which of the following terms describes an insurance company paying the physician a set amount each month, regardless of the number of services the patient receives? A. payment scale B. monthly dividend C. capitation D. coinsurance

C capitation

A patient presents for a procedure that Medicare will not pay for. Which of the following should the billing and coding specialist do? A. Collect payment in full before the procedure. B. Ask the doctor if only the allowable should be billed. C. Have the patient sign an advanced beneficiary notice. D. Obtain a letter of medical necessity.

C. Have the patient sign an advanced beneficiary notice.

An Advance Beneficiary Notice must be signed A. before a series of covered services. B. prior to the start of any surgical procedure. C. before a service which is not covered is provided D. prior to a procedure when the risk of death is high.

C. before a service which is not covered is provided

To verify that multiple CPT® codes may be billed together without being considered unbundled, the insurance and coding specialist should query the A. CPT® coding nomenclature. B. private payer's policy guidelines. C. NCCI edits. D. clearinghouse.

C. NCCI edits. NCCI edits are published by Medicare as guidelines to their coding practices. NCCI edits contain services that are bundled together and should not be billed separately. Please note that not every code is mentioned in the NCCI edits, but should always be reviewed for information. Even though these edits are published for Medicare patients, many other insurances also use these guidelines.

A claim that is not missing information is called A. dirty. B. pending. C. clean. D. scrubbed.

C. clean.

The provider has a capitation plan that states he will provide examinations for 100 employees. The insurer will reimburse at the rate of $100 per employee, paid in monthly installments. During the month of March only 80 patients were provided exams. Which of the following is the expected reimbursement for March? A. $800 B. $1,000 C. $8,000 D. $10,000

D $10,000

Payment received from the payer based on the number of enrollees and entered as monthly payment to the ledger is called A. fee for services. B. premium. C. EFT. D. capitation.

D capitation. Capitation is the payment system in which the carrier will pay the provider monthly for each patient who is enrolled, regardless if the patient was seen or not. An EFT, electronic fund transfer, is the way that payments are made by the carriers to the physician. A premium is the cost of the insurance, that is paid by the patient to the carrier. Fee for services determines how much should be paid for each service, depending on where the patient is seen.

Which of the following documents includes details of fees for services rendered in a clinical setting? A. charge master B. sliding scale C. financial responsibility form D. encounter form

D encounter form An encounter form is used and generated by the practice. An encounter form is used for each patient visit and included details of the services rendered and the fees associated with those services. A charge master is used by the practice to keep track of the prices of the services provided by the practice. A financial responsibility form is used to document the person who is responsible for paying for services.

Charge information can be taken from an encounter form and entered into the patient's A. registration. B. case. C. history. D. ledger.

D ledger. Charge information can be taken from an encounter form and entered into the patient's ledger. A patient encounter form contains the information on the services rendered to that patient for that day. The services rendered can be applied from the encounter form to the patient ledger card, which is a running monetary balance owed by the patient. A ledger is balanced similarly to a check book, adding new fees and subtracting credits paid.

How often does a capitation payment get applied to a patient's account? A. weekly B. annually C. quarterly D. monthly

D monthly

Which of the following information will result in a rejected claim if left off a CMS 1500 form? A. dates of inpatient stay B. outside lab C. amount due D. place of service

D place of service