Study Guide -- Insurance Processing

Which of the following forms should be transmitted to obtain reimbursement following a physician's office visit for a patient with active Medicaid coverage? A. CMS-1500 B. CMS-1450 C. Private Pay Agreement D. UB-04

A. CMS-1500 The specific type of insurance plan is selected in block 1 of the CMS-1500 (Centers for Medicare/ Medicaid Services) claim form. A UB-40 form (a.k.a. CMS-1450) is a standard form used for claims billed to Medicare Administrative Contractors. In a private pay agreement, the patient pays for the service or procedure.

Which type of insurance begins direct payment to the patient after they have been injured and unable to work for a specific period of time? A. Disability B. Worker's Compensation C. Medicaid D. TRICARE

A. Disability The purpose of Disability payments is to replace income the patient has lost due to their disability (short term or long term) - claim forms must be proofread carefully and signed by the physician. Workers' compensation is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee's right to sue his or her employer for the tort of negligence. Medicaid is a joint federal and state program that helps low-income individuals or families pay for the costs associated with long-term medical and custodial care, provided they qualify. Although largely funded by the federal government, Medicaid is run by the state where coverage may vary. Tricare, formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System.

For reimbursement purposes, the medical assistant should check to make sure that which of the following key pieces are provided on the insurance claim form? A. ICD-9-CM and CPT codes B. EOB and insurance premium C. ICD-9-CM codes and insurance premium D. EOB and CPT codes

A. ICD-9-CM and CPT codes Proper ICD-CM and CPT codes are key pieces that help to minimize the possibility of a claim being rejected due to missing and/or incorrect information (a.k.a. a "dirty claim"). The explanation of benefits (EOB) and insurance premiums are not a part of the claim form. An explanation of benefits is a document sent to the patient that explains what payments/adjustments will be made for services received. Premiums should be paid by the patient to the insurance company, and the provider is not a part of this process.

Which of the following plans, funded by state and federal funds, exists to aid those with a limited or low income with health care costs? A. Medicaid B. Medicare C. CHAMPVA D. Blue Cross/Blue Shield

A. Medicaid Medicaid is program of medical aid designed for those unable to afford regular medical service and financed jointly by the state and federal governments A patient's coverage must be verified at each visit, preauthorization is required for some services to obtain reimbursement. Medicare is a government program of medical care especially for the elderly or handicapped. CHAMPVA is a health benefits program in which the Department of Veterans Affairs (VA) shares the cost of certain health care services and supplies with eligible beneficiaries. Blue Cross/Blue Shield is one of many public insurance companies providing insurance with coverage that may vary by state.

Which part of Medicare covers hospitalization expenses? A. Part A B. Part B C. Part D D. Medicare supplement policies

A. Part A Benefits are received when a person becomes eligible for Social Security. Medicare is for people age 65 or older, and for those who are disabled or are on renal dialysis. Medicare has two parts. Medicare Part A covers hospital stays and other inpatient services. Part B covers physician and other outpatient services, medically necessary services and preventive services, Part D covers the prescription drug coverage and Medicare supplement policies address gaps in coverage.

What items are needed to submit a prior authorization request? A. Proper ICD-9(10)-CM and CPT codes B. Proper ICD-9(10)-CM code only C. Proper CPT code only D. Proper HCPCS code only

A. Proper ICD-9(10)-CM and CPT codes In many cases, prior authorization is necessary in order for insurance coverage. Some drugs require prior authorization (i.e. a physician may need to request and receive approval before prescribing a drug). The request form should contain the proper ICD-9(10) and CPT codes associated with the particular reason for the request. HCPCS codes are not generally needed in this case.

Which of the following health care benefit plans primarily serves active duty and retired uniformed military service members and their families? A. TRICARE B. Medicare C. Medicaid D. Federal Employees Health Benefits (FEHB) Program

A. TRICARE Health care providers must be approved to accept patients with TRICARE (formerly CHAMPUS); preauthorization is required for some services. Medicaid is program of medical aid designed for those unable to afford regular medical service and financed jointly by the state and federal governments. Medicare is a government program of medical care especially for the elderly or handicapped. FEHB is only available to Federal employees, retirees and their survivors.

Which of the following front office tasks performed by the medical assistant describes the translation of words into numbers so that insurance claims may be filed? A. coding B. annotating C. indexing D. alpha-numeric labeling

A. coding The medical assistant understands that coding assigns a certain numeric value to a medical diagnosis, surgery, procedure, symptom(s) of a disease and medical care for insurance processing and reimbursement. Example: CPT or ICD-CM. Annotation involves explanation through notes/commentary. Indexing is performed by entering information into a database or record for historical storage and retrieval. The labeling process for files, charts, etc. can utilize an alpha-numeric system.

Prior approval from an insurance company for the cost of services is known as which of the following? A. preauthorization B. informed consent C. professional liability D. assignment of benefits

A. preauthorization Precertification is the process of finding out if a service or procedure is covered under a patient's insurance policy. Once it's determined that a procedure/service is covered, permission (preauthorization) must be obtained from the insurance provider. Predetermination is based on a medical professional's review of the patient's medical needs to determine if the procedure/service is appropriate. Informed consent is obtained when a provider explains the procedure to the patient and the patient acknowledges that he/she is making an informed decision when consenting to said procedure. Professional liability means that a professional has a legal obligation to offer appropriate standard of care (and not be negligent or omit certain components of care).

The main purpose for verifying a patient's insurance coverage at every visit is to A. prevent claim rejection due to ineligibility or non-active status. B. maintain confidentiality of protected health information. C. expedite the age analysis process of delinquent accounts. D. establish rapport and respectful approach to care.

A. prevent claim rejection due to ineligibility or non-active status. This also ensures the correct insurer is billed and facilitates timely reimbursement for the provider. The medical assistant should scan into the EHR or make a copy of both sides of the patient's current insurance card.

A child is covered by the insurance policies of each of his parents: United Health Care and Blue Cross/Blue Shield. According to the birthday rule, which of the following plans should become the primary insurance? A. the plan of the policyholder whose birthday comes first in the calendar year B. the plan of the policyholder whose birthday comes last in the calendar year Insurance Processing C. the plan of the policyholder that is least expensive per month D. the plan of the policyholder that has the lowest annual deductible

A. the plan of the policyholder whose birthday comes first in the calendar year The birthday rule applies to month and day, not year. Example: The plan of the parent whose birthday is in January would become the primary insurance policy for the child if the other parent's birthday is in June.

Which of the following forms should the medical assistant submit to request insurance reimbursement for a physician's office visit? A. Assignment of Benefits B. CMS-1500 C. Assumption of Liability D. Explanation of Benefits

B. CMS-1500 CMS-1500 is a standardized claim form that healthcare providers submit for Medicare reimbursement (Universal Claim Form - Centers for Medicare and Medicaid Services). A patient can authorize payment directly from the insurance company to the health care provider with an assignment of benefits. An explanation of benefits (EOB) explains what payments/adjustments will be made for services received. The EOB is sent directly to the insured patient. Assumption of liability relates to a patient assuming liability for any expenses incurred (either the balance of what insurance does not pay or the entire bill).

Which of the following statements describes managed care? A. Coverage is normally provided for elective procedures. B. Cost-containment is a primary goal. C. Pre-authorization is required for emergency care. D. Pre-certification is not necessary for reimbursement.

B. Cost-containment is a primary goal. A managed care system manages healthcare services in an effort to control costs. Under such plans, elective procedures are often either not covered or very minimally covered. Emergency care by nature should not require pre-authorization. If the situation is emergent, the patient is allowed to receive care. The managed care system generally links reimbursement to precertification of procedures. If a qualifying procedure is not pre-certified, the patient is at risk of not receiving reimbursement.

Which of the following government sponsored health insurance programs primarily serves older adults over 65 years of age? A. TRICARE B. Medicare C. Medicaid D. Workers' Compensation

B. Medicare Persons under 65 years of age with severe disabilities, or permanent kidney failure, or amyotrophic lateral sclerosis (ALS) may also qualify for Medicare coverage. Medicaid is a joint federal and state program that helps low-income individuals or families pay for the costs associated with long-term medical and custodial care, provided they qualify. Although largely funded by the federal government, Medicaid is run by the state where coverage may vary. TRICARE, formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System. Workers' compensation protects workers who are injured or become ill on the job.

A Medicare patient presents to an outpatient hospital facility for a scheduled hysterectomy. To which Medicare plan should the facility submit the claim? A. Medicare Part A B. Medicare Part B C. Medicare Part C D. Medicare Part D

B. Medicare Part B This claim should be submitted to Medicare Part B since it is an outpatient medical procedure. Medicare Part A basically covers inpatient care, but can expand to cover hospice and home health in a limited capacity. Medicare Part B is generally referred to as medical insurance that covers outpatient visits, services and supplies. Medicare Part C (a.k.a. Medicare Advantage) is an additional option for private insurance on top of A and B. Medicare Part D is associated with prescription drugs.

Which part of Medicare covers office visits with a primary care provider? A. Part A B. Part B C. Part C D. Part D

B. Part B A monthly premium and meeting an annual deductible are standard to qualify, after which an 80% reimbursement rate will take effect - the insured is responsible for the 20% coinsurance. [Part A - hospital insurance, Part B - helps to offset costs not covered by Part A, Part C - Medicare Advantage, allows beneficiaries to select a managed care plan as their primary coverage Part D - prescription drug coverage, helps with coverage of some medications.]

A physician has admitted a patient to the hospital for shortness of breath. After reviewing the patient's medical record, the hospital coder codes the admission as 99223. On which of the following claim forms should the hospital coder submit this patient's charges? A. spend down B. UB-04 C. ABN D. CMS-1500

B. UB-04 A UB-04 form (a.k.a. CMS-1450) is a standard form used for claims billed to Medicare Administrative Contractors. An ABN is an advanced beneficiary notice and is used when patients choose to have procedures/services that may not be covered by insurance (patient gives informed consent to pay if insurance does not cover). Spend down is terminology that describes a situtation where the patient has too many assets (or too high an income) to qualify for benefits such as Medicaid. This requires the patient to use up this money before they reach levels of benefit eligibility.

Premiums are payments made systematically to insurance companies in exchange for which of the following? A. kickbacks B. benefits C. referrals D. adjustments

B. benefits Payments of premiums must be maintained to keep an insurance policy in active status. Referrals and adjustments do not effect benefits received from insurance coverage. Kickbacks are mostly known as questionable practice within the insurance industry and is coming under increased scrutiny.

Request for payment under the terms of a health insurance policy is referred to as which of the following? A. deductible B. claim C. preauthorization D. copayment

B. claim Once submitted, claims are reviewed by the insurance company and paid out to the insured (or authorized billing representative) when approved.

Hospitalization benefits under insurance plans are usually limited to a total monetary amount or a maximum number of A. patients. B. days. C. sickness. D. hospitals.

B. days. Insurance plans generally list benefits for hospitalization separately from other benefits. Most plans set limits based on a total amount to be paid on the insured's behalf or a maximum number of days in the hospital that will be covered.

Which of the following insurance related forms includes a detailed description of benefits paid, reduced, or denied on a claim? A. coordination of benefits B. explanation of benefits C. service benefit plan D. assignment of benefits

B. explanation of benefits The medical assistant examines the explanation of benefits (EOB) for accuracy, and posts payments and/or adjustments on the patient's account. For Medicare reimbursement, this is called Explanation of Medicare Benefits (EOMB). It is known as a Remittance Advice (RA) for Medicaid.

A medical office assistant can recognize Current Procedural Terminology (CPT®) codes because they are A. alpha-numeric codes. B. five digit codes. C. three, four, and five digit codes. D. four digit codes.

B. five digit codes. Current procedural terminology (CPT) codes are made up of five numbers. CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding System. The Current Procedural Terminology (CPT) was developed by the American Medical Association (AMA). Other types of file identification can include color, alpha, numeric or other coding in addition to CPT.

Employees of a major automobile manufacturer are provided health insurance under a master contract issued to their employer. Which of the following types of coverage does this reflect? A. indemnity plan B. group policy C. coinsurance D. fee-for-service plan

B. group policy The majority of people in the United States (approximately 60%) receive their health insurance through employer-sponsored group plans. Under an indemnity plan, the insurance company pays a percentage of each covered healthcare service after it is rendered. In a Fee-for-service plan, the healthcare providers set the fees for each of the services used on that patient for that visit and the payment is on a per service basis (not bundled). Coinsurance is a form of shared payment usually framed as a percentage. That percentage reflects the patient's responsibility for each instance of care.

Which of the following types of coverage provide protection up to a maximum limit in cases of catastrophic or prolonged illness? A. basic medical B. major medical C. hospitalization D. long-term care

B. major medical Major Medical coverage usually takes effect after the patient's deductible and co-insurance have been met. Basic medical insurance covers normal care (i.e. office visits, outpatient care). Some hospitalization and long-term care may still be covered under most primary insurance plans

Which of the following should the medical assistant assign to a patient's main CPT® code, indicating unusual circumstances were present related to the procedure? A. E/M code B. modifier C. symbol D. V code

B. modifier The addition of a modifier to a code provides a path for the provider to signify additional information or circumstances were present for a given code. The modifier -50 indicates a bilateral procedure was performed at the same time. V codes are used to indicate an encounter with no current illness or injury. Depending on the medical situation, V codes can be the primary (listed first) or secondary (contributing) code. E/M coding deals with evaluation and management. E codes are considered supplemental. They are used to list an external cause (i.e. what caused the injury).

An added feature to a patient's insurance policy expanding or placing limits on standard coverage is a A. referral. B. rider. C. deductible. D. precertification.

B. rider. Insurance benefits may be increased or decreased. For instance, a rider (an extra provision in an insurance policy that alters coverage) can exclude coverage for preexisting conditions for a specific period of time or add benefits for long-term care. A referral indicates to the physician to be seen (likely a specialist) that the primary care physician (PCP) feels the patient should seek further care from the other physician (specialist). The patient's out-of-pocket expense due prior to insurance company coverage taking effect is known as the deductible. Precertification is the process of finding out if a service or procedure is covered under a patient's insurance policy.

The physician asks the medical assistant to choose an E/M code indicating 40 minutes were spent on an office visit that actually took less than 15 minutes. This is an example of which of the following? Insurance Processing A. adding a modifier B. upcoding C. unbundling D. capitation

B. upcoding This is an example of upcoding, a deliberate upgrading of medical coding to gain benefit. It is illegal to purposely "upcode" an encounter for any reason. The coding system is specific and should be diligently followed. Adding a modifier to codes can further explain circumstances of a particular visit. E/M codes are for evaluating and management of the patient's care, billed and paid by the amount of time that a physician has spent with the patient and the vitals measured during the intake. Capitation is a payment method used by managed care offering a fixed amount for services rendered, no matter how many time a covered patient seeks care.

Which of the following patients below meet Medicare's eligibility criteria? A. 45 year old man who suffered a back injury and hasn't been able to work for 9 months. B. 61 year old woman who recently retired from the local school district. C. 23 year old woman that has been blind since birth. D. 53 year old man who received a liver transplant

C. 23 year old woman that has been blind since birth. Medicare is a Federal health insurance program which provides coverage for those who qualify over age 65 or under age 65 with a disability (unable to work). All other individuals could utilize their retirement insurance benefits through their work, long term disability or workers compensation or even Medicaid depending on their circumstances.

A medical office assistant in the primary care physician's office must complete a managed care referral for a patient A. after the visit. B. at the time of the visit. C. prior to the visit. D. within 90 days of the visit.

C. prior to the visit. A managed care referral should be used according to insurance company guidelines. The referral indicates to the physician to be seen that the primary care physician (PCP) feels the patient should seek further care from the other physician (specialist). This serves to inform the insurance company that the PCP has approved the visit. This needs to occur before the patient appointment as required by most insurance companies.

The phlebotomist needs to draw routine labs. The skin preparation for this procedure would be. A. Sterilize the site by using a circular motion from the center to the periphery. B. Disinfect the site by using a circular motion from periphery to center C. Cleanse the site by using a circular motion from center to periphery D. Sterilize the site by using a circular

C. Cleanse the site by using a circular motion from center to periphery Phlebotomists cleanse the selected venipuncture site before routine lab draws. Cleansing is accomplished by moving the alcohol pad in a circular motion from the center to the periphery of the puncture site. The alcohol pad is sterile at first touch to the patient's skin and thereafter will contain surface bacteria from the skin. If a blood culture is ordered, disinfection is required before the collection; disinfection devices can vary among institutions, but often include an isopropyl pad and providone iodine swab and possibly the PREP method (70% isopropyl/10% acetone scrub and povidone iodine dispenser). Total sterilization of the skin is not possible.

A patient is referred to a specialist by the primary care provider. Pre-certification is required for this patient's specialty visit. Which of the following actions is required by the medical assistant to obtain authorization? A. Contact the patient's specialist. B. Have the patient submit a paper claim. C. Contact the patient's insurance provider. D. Submit the CMS 1500.

C. Contact the patient's insurance provider. Pre-certification (authorization for the service) should be obtained from the insurance provider. In this case, the medical assistant should contact the insurance provider for this authorization. A CMS 1500 form is not warranted at this time, nor would a claim form submitted by the patient be effective here.

A patient presents to the provider's office with a complaint of persistent migraines three days after acquiring a head injury on the job. After the provider assesses the patient, the final diagnosis is a concussion. Which of the following actions should the medical assistant take next? A. File a claim with the patient's primary insurance carrier. B. Bill the patient's employer directly. C. Determine if a workman's compensation claim has been filed. D. Obtain payment directly from the patient at the time of service

C. Determine if a workman's compensation claim has been filed. Whenever a patient claims a workplace injury, the health care provider should call the employer to see if a workman's compensation claim has been filed. If so, billing will first go through that claim. The other options listed in this scenario would be follow-up based on whether or not a workman's comp claim has been filed.

The provider prescribed and ordered a wheel chair for a patient with a below the knee amputation. Which of the following manuals should the medical office assistant use to code these services? A. ICD-10-CM B. CPT C. HCPCS D. CPT-assistant

C. HCPCS A wheel chair is classified as durable medical equipment. A prescription for a wheel chair would be coded for in the HCPCS. Healthcare Common Procedure Coding System (HCPCS) level II codes address durable medical equipment and other services not in the level I Current Procedural Terminology (CPT) codes. ICD (International Classification of Disease) codes are associated with the diagnosis/disease instead of procedures.

When billing for durable medical equipment, a medical office assistant should use which of the following codes? A. CPT B. ICD C. HCPCS D. Level III

C. HCPCS Healthcare Common Procedure Coding System (HCPCS) level II codes address durable medical equipment and other services not in the level I Current Procedural Terminology (CPT) codes. ICD (International Classification of Disease) codes are associated with the diagnosis/disease instead of procedures. Level III HCPCS codes were used for local supplies and services, previously referred to as miscellaneous codes.

The physician asks the medical assistant to fill out a CMS-1500 for a patient who came in for a 30 minute office visit and was treated for hypertension. Which of the following should the medical assistant use to locate the code for hypertension? A. CPT B. NPI C. ICD-CM D. HCPCS

C. ICD-CM CMS-1500 refers to a standardized claim form that healthcare providers submit for Medicare reimbursement. A portion of this form requires ICD coding. ICD-10-CM stands for: International Classification of Diseases, Tenth Revision, Clinical Modification. This is a classification system which assigns codes for different diagnoses, symptoms and procedures asserted, applied and received during a visit to a health care provider. CPT (Current Procedural Terminologydeveloped and overseen by the American Medical Association) codes are considered the first level of the HCPCS (Health Care Procedure Coding System). CMS (Centers for Medicare and Medicaid Services) issues every provider of health care in the United States an identification number called an NPI (National Provider Identifier).

Which of the following actions should the medical assistant take when handling a worker's compensation claim? A. Ensure the patient has obtained legal representation prior to seeking care. B. Process the claim according to disability income insurance guidelines. C. Promptly verify the patient's insurance coverage with their employer. D. Bill the patient directly to collect outstanding reimbursement for treatment.

C. Promptly verify the patient's insurance coverage with their employer. It would be promptly necessary to ensure compliance for care reimbursement. In order to do that, the MA would verify the patient's insurance coverage with their employer. The goal of worker's compensation laws are to provide prompt care to the patient in order to restore optimum health, and allow them to return to maximum earning capacity as soon as possible. The medical assistant should verify the employer's coverage for work-related illness or injury. A claim may be rejected if not filed within the statutory time limit. Examples: an overexertion injury from lifting, or a slip on a wet surface that causes the person to fall to the floor or ground.

A 64 year old indigent veteran (recently diagnosed disabled but has a part-time job) receiving outpatient peritoneal dialysis was referred to his federal primary care provider for stomatitis. The patient then went to his PCP for an assessment plan and IV antibiotics. The patient died at 2:00 pm the following day, on his 65th birthday. Which of the following entities should be billed for the medical expenses? A. Medicare B. Veterans Administration C. Tricare D. Medicaid

C. Tricare www.Medicare.gov is a great website for recent information about how to manage multiple government health care providers. A guide to who pays first can be found at the following link: http://www.medicare.gov/Pubs/pdf/02179.pdf. In this case, the patient's veteran status allows coverage under Tricare. The patient is undergoing dialysis, indicating End Stage Renal DiseaseESRD, which qualifies him for Medicare. The disability would also entitle the patient to Medicare coverage, but the fact that the diagnosis is recent translates that the paperwork likely has not gone through on this coverage yet. The Veterans Administration would not be billed because they are not an insurance company and the patient was not in a VA Hospital. Tricare pays the bills for services provided from any federal health care provider, including a military hospital. In this case, even though the patient is entitled to Medicare, Tricare should cover the cost for the services rendered.

A parent brings their four-year old in for a well-child exam. The medical assistant should assign an ICD-CM code beginning with which of the following? A. E B. M C. V D. +

C. V V codes are used to indicate an encounter with no current illness or injury. Depending on the medical situation, V codes can be the primary (listed first) or secondary (contributing) code. E/M coding deals with evaluation and management. E codes are considered supplemental. They are used to list an external cause (i.e. what caused the injury). "+" is not a commonly used symbol in the medical coding system.

Which of the following forms must be signed by the patient and kept on file, allowing physicians to be paid directly from the insurance carrier? A. HIPAA waiver B. CMS-1500 C. assignment of benefits D. living will

C. assignment of benefits A patient must sign an assignment of benefits form to allow the insurance company to pay the health care provider directly. The CMS-1500 form is the official standard Medicare and Medicaid health insurance claim form. A HIPAA waiver is associated with the privacy and protection of health care records. An advanced directive (a.k.a. living will) is a document outlining the patient's wishes regarding treatment to prolong life.

Which of the following prevents duplication of payment by more than one insurance carrier? A. fee-for-service B. precertification C. coordination of benefits D. preauthorization

C. coordination of benefits Coordination of benefits is needed when a patient is covered by one or more plan (i.e. insurance and Medicare) to determine how much and for which services each plan is responsible for paying. The primary insurance carrier must be determined (and billed first) to ensure record accuracy. Precertification is the process of finding out if a service or procedure is covered under a patient's insurance policy. Once it's determined that a procedure/service is covered, permission (preauthorization) must be obtained from the insurance provider. Fee-for-service (FFS) delivery systems pay providers for each service rendered. For instance, a separate fee will be paid for the office visit, lab tests, x-ray, etc.

Which of the following is the predetermined amount of total eligible charges a patient must pay before insurance plan benefits begin? A. premium B. coverage C. deductible D. copay

C. deductible The patient's out-of-pocket expense due prior to insurance company coverage taking effect is known as the deductible. Part of the deductible can be met with copays (the amount the patient pays at the time of service- generally a set amount based on in-network or out-of-network visits). The premium is the amount of money the insurance company charges for coverage. Coverage (which procedures, visits, etc. are eligible for insurance payment) can vary among insurance plans. The more coverage an insured person has, the higher the insurance premiums.

If a provider charges for services that were not performed, it is considered A. a clerical error. B. abuse. C. fraud. D. a HIPAA violation.

C. fraud. This would be an example of fraud, which is when one person is intentionally deceitful in order to gain money. A clerical error would occur if the provider's assistant or secretary accidentally made a mistake. Abuse can occur in many forms, resulting in someone or something being treated improperly. A HIPAA (Health Insurance Portability and Accountability Act) violation occurs when a healthcare provider discloses information that is supposed to be confidential.

A provider who has a contractual agreement to accept an insurance company's prenegotiated rate for health care services is considered to be A. for-profit. B. not-for-profit. C. in-network. D. non-network.

C. in-network. Insurance can be tricky. One way providers and insurance companies work together is to prenegotiate rates for services. The provider is then considered in-network (also called participating, authorized, or network provider). Those providers who do not have an accepted rate agreement are considered out of network (or non-network). For-profit and not-for-profit status should not affect the medical care received. The main difference is the accounting: When for-profits make money, the shareholders make money. Non-profit organizations don't typically have shareholders and they get income and property tax exemptions that for-profits don't.

The process of finding out if a service or procedure is covered under a patient's insurance policy is called A. predetermination. B. preauthorization. C. precertification. D. preexisting.

C. precertification. Precertification is the process of finding out if a service or procedure is covered under a patient's insurance policy. Once it's determined that a procedure/service is covered, permission (preauthorization) must be obtained from the insurance provider. Predetermination is based on a medical professional's review of the patient's medical needs to determine if the procedure/service is appropriate. A preexisting condition.

A patient sustained broken ribs in an automobile accident in which she was the passenger. After completion of an office follow up visit, which of the following should the medical office assistant submit the insurance claim to first? A. the patient's primary health insurance B. the patient's automobile insurance C. the driver's automobile insurance D. the driver's primary health insurance

C. the driver's automobile insurance In case of an automobile accident, a victim/patient would be covered under the driver's liability/auto insurance. If the patient also has health insurance, this would require a coordination of benefits to decide which coverage would be primary and secondary. The claim in this instance would be first submitted to the driver's insurance. Depending on the policy and other variables, the patient's automobile insurance and the patient's primary health insurance might pay part of the balance unpaid by the driver's auto insurance.

When filing an electronic insurance claim, the medical assistant processes which of the following forms? A. HIPAA waiver B. encounter form C. assignment of benefits D. CMS-1500

D. CMS-1500 CMS -1500 is a form that is used to process insurance claims for payments, electronic or hard copy, HIPAA waiver is to allow provider to give information regarding your care. Encounter form is the record of the daily, individual visits, and assignment of benefits is stating that the payment can go directly to the provider.

A medical office assistant is reviewing a chart with the following documentation: patient presented with a complaint of itchy, red bumps on her chest and neck. Diagnosis: Urticaria, Procedure: Expanded Office Visit. The coding reference manual that would contain the term Urticaria and the associated code is the A. Current Procedural Terminology (CPT) code book B. Health Care Financing Administration Common Procedure Coding System (HCPCS) code book C. Centers for Medicare and Medicaid Services (CMS) code book Insurance Processing D. International Classification of Diseases (ICD) code book

D. International Classification of Diseases (ICD) code book Urticaria is a type of skin rash commonly known as hives. In the scope of medicine, this diagnosis is considered the "disease" and would be found in the International Classification of Disease (ICD) reference manual. CPT and HCPCS are both associated with procedures. CMS is the Centers for Medicare & Medicaid Services and requires forms to be filled out (to include applicable ICD, CPS and HCPCS codes).

Which is the correct procedure for keeping an industrial patient's financial and health records when the same physician is also seeing the patient as a private patient? A. The same financial record may be used but a separate health record must be maintained. B. The same health record may be used but a separate financial record must be maintained. C. The same financial and health records may be used. D. Separate financial and health records must be used.

D. Separate financial and health records must be used. An industrial patient may have a record at a health care provider for a workman's compensation incident. If that patient also uses that same provider for personal medical care, personal health and financial records should be kept separate from the workplace related records. By law, medical records requested for workers' compensation cases should contain information exclusively associated with the injury or condition related to work.

Which of the following patient documents should a medical office assistant refer to in order to complete the patient information question block section of the CMS-1500 form? A. health history form B. release form C. HIPAA form D. registration form

D. registration form The patient registration form would include information that would pertain to the patient information question block section on a CMS-1500 form.

While a new patient is in the examination room with a physician who is explaining treatment options to the patient, the medical office assistant is contacting the insurance carrier to discuss the patient's insurance coverage. This scenario is an example of obtaining A. a preauthorization for the patient. B. a statement of probable cause. C. a disclosure of benefits and eligibility for the patient. D. verification of benefits and eligibility for the patient.

D. verification of benefits and eligibility for the patient. It is important to verify what benefits and eligibility the patient has under the insurance policy. This will assist all involved in determining the next course of action. If there are options for treatment, the patient and provider need to know what is and what is not covered before choosing a treatment plan. A preauthorization, probable cause, or referral may be indicated, but the first thing to determine is the patients benefits and eligibility, then follow up accordingly.