Understanding Health Insurance - Chapter 12

Block 24A of the CMS-1500 claim contains dates of service (FROM and TO). If a procedure was performed on May 10, YYYY, in the office, what is entered in the TO block? 1) 0510YYYY 2) 05 10 YYYY 3) 05-10-YY 4) 05-10-YYYY

05 10 YYYY

The policyholder's commercial group number if the patient is covered by a group health plan is entered in which block of the CMS-1500? 1) 11 2) 11c 3) 11a 4) 11d

11

An X in the YES box of Block 20 indicates that: 1) There is another health benefit plan 2) The patient's condition is related to employment 3) An outside lab was used 4) The provider accepts assignment

An outside lab was used

When Block 25 of the CMS-1500 contains the provider's EIN, enter _____ after the first two digits of the EIN. 1) A space 2) A hyphen 3) No punctuation or space 4) The provider's SSN

No punctuation or space

When a child who is covered by two or more plans lives with his married parents, the primary policyholder is the parent 1) Whose birthday occurs first in the year. 2) Who is older. 3) Whose birthday occurs later in the year. 4) Who is younger.

Whose birthday occurs first in the year.

When completing a CMS-1500 claim using computer software, text should be entered in _____ case. 1) Small caps 2) Upper 3) Title 4) Lower

Upper

Often a commercial payer will implement changes to claims completion requirements throughout the year, and most providers discover these changes: 1) On the superbill 2) From their explanation of benefits 3) On the accept assignment form 4) When claims are denied

When claims are denied

Nancy White's employer provides individual and family group health plan coverage, and it pays 80 percent of her annual premium. Nancy selected family coverage for her group health plan, which means her employer pays $12,000 per year (of the $15,000 annual premium). Nancy is responsible for the remaining $3,000 of the annual premium, which means approximately _____ is deducted from each of her 26 biweekly paychecks. 1) $90 2) $100 3) $115 4) $125

$115

Block 14 of the CMS-1500 claim requires entry of the date the patient first experienced signs or symptoms of an illness or injury (or the date of last menstrual period for obstetric visits). Upon completion of Jean Mandel's claim, you notice that there is no documentation of that date in the record. The provider does document that her pain began five days ago. Today is May 10, YYYY. What do you enter in Block 14? 1) 05 05 YYYY 2) 05 10 YYYY 3) The word NONE 4) Nothing (leave the block blank)

05 05 YYYY

The base period used to calculate an individual's weekly disability benefit amount usually covers: 1) 9 months and is divided into three consecutive trimesters 2) 6 months and is divided into three consecutive trimesters 3) 12 months and is divided into four consecutive quarters 4) 16 months and is divided into four consecutive quarters

12 months and is divided into four consecutive quarters

The birthday rule is used to determine the primary insurance policy when the patient is: 1) A child covered by two or more plans 2) Insured by her own employer and her spouse's employer 3) Injured in a collision with the policyholder's vehicle 4) Injured at his or her place of employment

A child covered by two or more plans

When a patient is covered by a primary payer plan and a different secondary payer plan: 1) One claim is submitted and the payer transfers claim data to the secondary payer 2) A primary claim is submitted to the primary payer with the remittance advice from the secondary payer as an attachment 3) One claim is submitted and each payer pays half of the charges 4) A primary claim is submitted to the primary payer and a new claim is generated and submitted to the secondary payer

A primary claim is submitted to the primary payer and a new claim is generated and submitted to the secondary payer

The patient's name should be entered into Block 2 as: 1) SUSAN B ANTHONY 2) ANTHONY, SUSAN, B 3) SUSAN B. ANTHONY 4) ANTHONY SUSAN B

ANTHONY, SUSAN, B

When the CMS-1500 claim requires a response to YES or NO entries, enter 1) A checkmark 2) An X 3) Either an X or a checkmark 4) Nothing

An X

The process whereby the patient allows the payer to directly reimburse the provider is called: 1) Accepting assignment 2) Authorization to release information 3) Coordination of benefits 4) Assignment of benefits

Assignment of benefits

Which type of insurance is considered risky yet is marketed to small business owners as a way to provide coverage to employees? 1) Indemnity insurance 2) Commercial health insurance 3) High-risk pool insurance 4) Association health insurance

Association health insurance

Entering SIGNATURE ON FILE in Block 12 of the CMS-1500 claim means that, in order to release medical information to the payer, the patient has signed a(n): 1) Source document 2) Assignment of benefits 3) Authorization 4) Encounter form

Authorization

Where is type of accident information indicated on the CMS-1500? 1) Block 9 2) Block 21 3) Block 10 4) Block 24

Block 10

What kind of claim is used for billing provider fee-for-service claims to commercial health insurance companies? 1) ANSI ASC X12N 2) CMS-1450 3) UB-04 4) CMS-1500

CMS-1500

An automobile insurance policy typically includes: 1) Collision, comprehensive, indemnity, and personal injury protection 2) Collision, high-risk pools, liability, and personal injury protection 3) Collision, comprehensive, liability, and personal injury protection 4) Collision, high-risk pools, indemnity, and personal injury protection

Collision, comprehensive, liability, and personal injury protection

When entering the patient's name in Block 2 of the CMS-1500 claim, separate the last name, first name, and middle initial (if known) with 1) Commas 2) Parentheses 3) Hyphens 4) Slashes

Commas

When an insurance company uses the patient's Social Security number as the patient's insurance identification number, Block 1a of the CMS-1500 claim 1) Is left blank, because Social Security numbers are private. 2) Contains the identification number without hyphens or spaces. 3) Contains the dashes associated with Social Security numbers. 4) Can contain spaces or dashes when the number is entered.

Contains the identification number without hyphens or spaces.

Jaimie's parents are divorced and both cover her on their employer-sponsored health plans. There is no documentation from the court indicating which parent should provide healthcare coverage. How does the office determine which parent's coverage is primary? 1) Alternate between the mother's and father's coverage. 2) Assume the father's coverage is primary. 3) Determine which parent has custody. 4) Bill both at the same time and whichever one pays must be primary.

Determine which parent has custody.

Which insurance is defined as reimbursement for income lost as a result of a temporary or permanent illness or injury? 1) Liability 2) Disability 3) Fee-for-service 4) Indemnity

Disability

Reimbursement for lost income as a result of a permanent or temporary illness or injury is known as: 1) Workers' compensation 2) Disability insurance 3) Liability insurance 4) Commercial health insurance

Disability insurance

When a patient is covered by a large employer group health plan (EGHP) and Medicare, which is primary? 1) Medicare 2) The plan that has been in place longest 3) No distinction is made between the plans 4) EGHP

EGHP

Commercial individual health insurance policies are regulated by individual states and include the following: 1) Liability insurance, high-risk pools, managed care, and personal injury protection 2) Indemnity insurance, high-risk pools, managed care, and association health insurance 3) Indemnity insurance, high-risk pools, managed care, and personal injury protection 4) Comprehensive, high-risk pools, managed care, and association health insurance

Indemnity insurance, high-risk pools, managed care, and association health insurance

The definition of primary insurance coverage is the: 1) Insurance plan that was in existence the longest 2) Insurance plan responsible for paying a claim first 3) First insurance to pay the claim 4) First insurance plan the patient lists on their registration form

Insurance plan responsible for paying a claim first

Diagnosis reference numbers are entered on the CMS-1500 claim to: 1) Report mortality data 2) Report morbidity data 3) Analyze quality of services provided 4) Justify medical necessity

Justify medical necessity

Which insurance covers losses to a third party caused by the insured, by an object owned by the insured, or on premises owned by the insured? 1) Comprehensive 2) Liability 3) Indemnity 4) Disability

Liability

Which involves securing a debtor's property as security or payment for a debt? 1) Outsourcing 2) Subpoena 3) Lien 4) Subrogation

Lien

The correct format for birth date entry on the CMS-1500 claim is: 1) MM DD YYYY 2) MMDDYY 3) MM DD YY 4) MMDDYYYY

MM DD YYYY

When the CMS-1500 claim requires spaces in the data entry of a date, the entry looks like which of the following? 1) MMDDYYYY or MMDDYY 2) MM-DD-YYYY or MM-DD-YY 3) MM/DD/YYYY or MM/DD/YY 4) MM DD YYYY or MM DD YY

MM DD YYYY or MM DD YY

Block 33a of the CMS-1500 claim contains the provider's 1) PIN. 2) SSN. 3) EIN. 4) NPI.

NPI

Which is entered in Block 11c of the CMS-1500? 1) Policyholder's commercial group number 2) Indication of secondary insurance coverage 3) Name of commercial health insurance plan 4) Policyholder's gender and birth date

Name of commercial health insurance plan

What type of form is used to file a claim with a liability payer? 1) CMS-1500 2) Patient billing statement 3) CMS-1450 4) First Report of Injury

Patient billing statement

When is it appropriate to enter SIGNATURE ON FILE in Block 12? 1) Patient has assigned benefits to the office 2) After the patient has provided their insurance information 3) The provider accepts what the insurance company reimburses 4) The provider participates with the patient's insurance

Patient has assigned benefits to the office

Characteristics of group health insurance include all the following except: 1) Coverage for employees regardless of health status 2) Limit exclusions for pre-existing conditions 3) Offers COBRA continuation coverage 4) Requires referrals from a primary care provider

Requires referrals from a primary care provider

When SIGNATURE ON FILE is the appropriate entry for a CMS-1500 claim block, which is also acceptable as an entry? 1) FILED 2) S/F 3) SIGNED 4) SOF

SOF

When a patient is covered by the same primary and secondary commercial health insurance plan, 1) Submit just one CMS-1500 to the payer. 2) Mail the remittance advice to the payer. 3) Send the secondary CMS-1500, but not the primary claim. 4) Complete and submit two CMS-1500 claims.

Submit just one CMS-1500 to the payer.

The contractual right of a third party payer to recover healthcare costs from the liable party is known as: 1) Coordination of benefits 2) Cost recovery 3) Subrogation 4) A lien

Subrogation

Which refers to the contractual right of a third-party payer to recover health care expenses from a liable party? 1) Arbitration 2) Subrogation 3) Appeal 4) Claims adjudication

Subrogation

Deductibles, copayments, and coinsurance are covered by what type of plan? 1) Employer group health 2) Supplemental 3) Primary 4) Managed care

Supplemental

What is entered in the shaded areas of Block 24? 1) Additional procedures and services 2) Descriptions of CPT and HCPCS codes 3) The rendering provider's NPI 4) Supplemental information to support reported services

Supplemental information to support reported services

Blocks 24A-24J of the CMS-1500 contain shaded rows, which can contain 1) Supplemental information, per payer instructions. 2) Additional dates of service and code numbers. 3) Modifiers that didn't fit in the unshaded block. 4) Attachments to the CMS-1500 claim.

Supplemental information, per payer instructions.

When multiple claims are submitted for the same patient because more than six procedures were reported: 1) The total for all services should be reported on one of the claims 2) The total charge should be the total of items reported on each claim 3) No totals are indicated 4) Only report the totals for the visits

The total charge should be the total of items reported on each claim