Chap 14 & 15 Review:

The patient's name is found in block

2

Procedures performed on the patient are found in what block?

24d

The federal tax identification number is found in block _________.

25

The physician's signature is located in block

31

The billing provider's NPI number is placed in block

33a

The insured's name is found in block

4

Susan Holms, a patient on Medicare, has met her deductible for the year. What percentage of her bill will be covered by Medicare?

80%

Secondary insurance policy information is contained in block __________.

9

The amount payable by an insurance company for a monetary loss to an individual insured by that company, under each coverage is called the___________________.

Benefits

Which of the following is typically documented in the estimation of benefits (EOB)?

Both A and B

Which of the following steps to medical billing should be performed prior to rendering medical services?

Both A and B

Preauthorization specifically determines the dollar amount approved for the medical procedure, while precertification gives the provider approval to render the medical service.

Both statements are false.

Which of the following expenses would be paid by Medicare Part B?

C. Physicians Office Visits

Joe Smith is a disabled serviceman who was honorably discharged from the military service. His wife and minor children are covered under an insurance program called...

CHAMPVA

Which of the following is a common reason why insurance claims are rejected?

Claim was sent to the wrong insurance plan

When the insurance company pays 80% of the charge and the patient pays the remaining 20%, this is called...

Co-insurance

Which of the following is a fixed amount per visit and is typically paid at the time of medical services?

Co-payment

Mary and Jim Smith both work and both participate in the health insurance plan offered by their separate employers. When Mary and Jim use their insurance, they are regulated by a term known as

Coordination of Benefits

Procedure code modifiers are found in column ___________ of block 24.

D

The amount of money paid to keep an insurance policy in force is the _____________________.

Premium

Most of today's health insurance policies cover which of the following?

Preventive Care and Procedures deemed medically necessary.

The abbreviation often used in blocks 12, 13, and 31 is ___________.

SOF

Which type of referral is usually processed immediately?

STAT

Which of the following referrals can be approved online when it is submitted through the provider's Web portal to the utilization review department?

STAT referral

The medical assistant should always verify which of the following prior to the patient's appointment? a. Eligibility b. Benefits and exclusions c. Effective date of insurance d. All of the above

d. All of the above

Which of the following plans require healthcare providers to become participating providers? a. All government-sponsored health plans b. Most privately sponsored health plans c. Indemnity health insurance plans d. Both A and B e. All of the above

d. Both A and B

Which statement is NOT true about Medicaid. a. Medicaid is for low income patients b. Physicians can choose whether to accept Medicaid patients c. Patients with Medicaid cannot be billed for services rendered at the office. d. Only patients over 65 qualify for Medicaid

d. Only patients over 65 qualify for Medicaid

Claims that have errors or omissions that must be corrected and resubmitted to receive reimbursment are called _____ claims.

dirty

Matchblock 21 with the appropiate content as it relates to completing the CMS-1500 form.

Diagnosis or nature of illness or injury

Transferring data back and forth between two or more entities.

Eletronic data interchange

The charges for procedures are listed in column ______ of block 24.

F

Claims that are done by direct billing first go to a clearinghouse.

False

Dirty claims cannot be resubmitted. (true or false)

False

Health insurance typically covers services and procedures considered medically necessary. Most insurance policies also cover "elective" procedures, such as certain cosmetic surgeries, that are not considered medically necessary.

False

TRICARE is a form of government insurance for veterans of the U.S. armed forces. (True or False)

False

How many diagnoses can be reported on the CMS-1500?

Four

A policy that covers a number of people under a single master contract issued to the employer or to an association with which they are affiliated and that is not self-funded is usually called

Group Policy

Which of the following pays the hospital surgical room fee?

Hospital

Which type of HMO model consists of physicians with separately owned practices who formally organize into a group but continue to practice in their own offices?

IPA - Independent Practice Association

The federal government's health insurance program for people age 65 and older is...

MEDICARE

Matchblock 14 with the appropiate content as it relates to completing the CMS-1500 form.

Date of current illness, injury, or pregnancy

Employee-sponsored group policies usually provide greater benefits at lower premiums because of the large pool of people from whom premiums are collected. However, these employee-sponsored group health insurance plans offer limited benefits, and healthcare access is limited to healthcare providers that are contracted with them.

The first statement is true; the second is false.

Assignment of benefits means..

The insurance payment will go directly to the physician.

A claim that is missing information and is returned to the provider for correction and resubmission is called a(n) ___________ claim.

incomplete

With an HMO, the patient..

must use HMO physicians

The date in block 14 is the date_______

of the onset of the illness.

The physician who enters into a contract with an insurance company and agrees to certain rules and regulations is called a ______ provider.

participating

Electronic claims are submitted via electronic media.

True

Insurance information should be collected on the first visit.

True

Nearly all of the physician's income is derived from the insurance payments received for services rendered.

True

Nearly all of the physician's income is derived from the insurance payments received for services rendered. (true or false)

True

The "cafeteria-style" plan allows employers to choose the benefits they want for their respective employees.

True

The insurance claim should always be proofread.

True

Block 1 of the CMS-1500 contains what information?

Type of insurance coverage

Which of the following is not a disadvantage of managed care? a. Authorized services usually are covered. b. Physicians' choices in the treatment of patients can be limited. c. More paperwork may be necessary. d. Reimbursement is historically less than with traditional health insurance.

a. Authorized services usually are covered.

Patients sign an ______ of benefits form so that the physician will recieve payment for services directly.

assignment.

Which of the following is not an advantage of managed care? a. Healthcare costs are usually contained. b. Access to specialized care and referrals is limited. c. Most preventive medical treatment is covered. d. Out-of-pocket expenses tend to be less than traditional insurance.

b. Access to specialized care and referrals is limited.

Entities that make payment on an obligation or debt but are not parties of the contract that created the debt are called

third-party payers

A review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources is called a(n)

utilization review

A type of insurance that protects workers from loss of wages after an industrial accident that happened on the job is called...

workers' compensation

The Federal Tax ID number (Box 25) for the provider filling the claim can be presented as

Both A and B

Veterans of the U.S. Armed Forces may be covered by

CHAMPVA

The yearly deductible for medicare patients is...

$166

If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay, how much will his insurance pay on his bill of $4,359?

$3,809

If Mr. Jones's insurance has a $500 deductible and a $50 surgery co-pay and then pays 80% of the charges, how much will his policy pay on his bill of $4,359?

$3047.20

Which of the following managed care plans require preauthorization for medical services such as surgery? A.HMOs B. PPOs C. EPOs D. Both A and B E. All of the above Correct

( HMOs & PPOs ) D. Both A and B

The physician's office place of service code is

11

The primary insurance policy information is contained in block ______________.

11

A secondary health plan is noted in which block

11d

The assignment of benefits is located in block

13

The maximum amount of money third-party payers will pay for a specific procedure or service is called the

Allowable Amount

To examine claims for accuracy and completeness before they are submitted to ___ the claims.

Audit

The federal- and state-sponsored health insurance program for the medically indigent is called

Medicaid

Which part of Medicare covers prescription drug services?

Medicare Part D

Match block 17 with the appropiate content as it relates to completing the CMS-1500 form.

National provider identification number

Under which of the following Medicare plans for primary care and specialists' services is the patient required to pay a monthly premium?

Part B

When completing the CMS-1500 Form, which section contains information about the patient and the insured?

Section 2

Dependents of military personnel are covered by which of the following government-sponsored health insurance plans?

TRICARE

Health insurance designed for military dependents and retired military personnel is called_________________.

TRICARE

The TRICARE option that is similar to a preferred provider network is?

TRICARE EXTRA

Under Medicare Part A, which of the following goods/services would be covered? a. Medications administered in the medical office b. Homemaker/health aide services c. Services in a hospital on an inpatient basis d. Canes and walkers purchased in a pharmacy

c. Services in a hospital on an inpatient basis

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

A(n) _______ claim has been completed accurately and completely.

clean

Claims submitted to a(n) _______ are forwarded to indivisual insurance carriers.

clearinghouse

The medical assistant should ___________ the front and back of the patient's insurance card.

copy

Health Insurance benefits are determined by? a) indemnity schedules. b) service benefit plans. c) relative value studies. d) All of the above

d) All of the above

The amount of money the policyholder pays per claim or per accident toward the total amount of an insured loss before the company will pay on the claim is known as the

deductible

The medical assistant should always follow office _______ for claim review and signatures.

policies

The insured's address in block 7 refers to the _____________ address

policyholder's

The medical assistant should do everything possible to prevent claim __________.

rejection

Organizations that fund their own insurance programs offer their employees

self-funded plans

Medigap policies cover which of the following? a. Difference between major medical reimbursement and patient financial responsibilities b. Difference between Medicare reimbursement and patient financial responsibilities c. Any services not covered under Medicare d. Any services not covered under Major medical

a. Difference between major medical reimbursement and patient financial responsibilities

Under Medicare Part B, which of the following goods/services would be covered? a. Durable medical equipment such as a wheelchair b. Surgery in a hospital c. Over-the-counter drugs d. Cosmetic surgery

a. Durable medical equipment such as a wheelchair

The maximum amount of money third-party payers will pay for a specific procedure or service is called the

allowable amount

Which of the following HMO models hires physicians and pays them a salary rather than contracting the physicians to create a network? a. IPA b. Staff model c. Group model d. PPO

b. Staff model

Which of the following individuals would not normally be eligible for Medicare? a. A 66-year-old retired woman Incorrect b. A blind teenager c. A 23-year-old recipient of AFDC d. A person on dialysis

c. A 23-year-old recipient of AFDC

Which of the following MCOs typically has/have the lowest monthly premiums with lower patient financial responsibility? a. Medicare/Medicaid b. PPOs c. HMOs d. BC/BS e. IPA

c. HMOs