Chapter 12

A participating provider of Blue Cross/Blue Shield sees a patient in the ER. The charges equal $500.00. The patient has a $1000 deductible of which none has been met, and a $75.00 ER copay. How much should be collected from the patient at the time of completion of the ER visit? a. $75.00 b. $1000.00 c. $500.00 d. Wait for the EOB as a contractual write-off will apply.

a. $75.00 Although the deductible has not been met, the patient has an ER co-pay of $75.00 that will be the amount due by the patient.

Jared is employed with the United States Internal Revenue Service and has enrolled in the Blue Cross/Blue Shield healthcare insurance offered through this employer. What is the name of the Blue Cross/Blue Shield insurance program offered by the federal government? a. FEP (Federal Employee Program) b. FWP (Federal Worker Program) c. FIP (Federal Insurance Program) d. GEP (Government Employee Program)

a. FEP (Federal Employee Program) The BC/BS Federal Employee Program (FEP) covers more than 5.3 million federal government employees, dependents, and retirees.

An indemnity plan is also referred to as _____________? a. Fee-for-Service b. Self-pay c. Health Savings account d. Preferred Provider Organization

a. Fee-for-Service An indemnity is a traditional plan or fee-for-service plan.

Which of the following information would NOT be found on an EOB? I. Claim total II. Adjustment applied to the submitted claim III. Amount paid IV. Patient's DOB V. Address of provider a. IV, V b. I, II, III c. II, III d. I, V

a. IV, V Patient's DOB (IV) and Address of provider (V), would not be found on the explanation of benefits form. The claim total, adjustment applied to the submitted claim and the amount paid will always be information reported on the EOB.

Blue Cross/Blue Shield identifies the individual who is eligible for covered services as the: a. Member b. Group c. Subscriber d. Beneficiary

a. Member A member is the person who is eligible for covered services.

Obtaining approval from the insurance payer before a procedure is performed is known as: a. prior authorization. b. prior approval. c. initial approval. d. initial authorization.

a. prior authorization. A prior authorization is required by insurance plans for many procedures. If the plan requires a prior authorization before receiving services and the provider fails to obtain one the claim can be denied.

What is the correct action when a claim has been submitted to BCBS but the provider has not received a response? a. Automatically refile the claim. b. Check claim status with the local BCBS carrier. c. Write-off the balance. d. Transfer the charges to patient responsibility.

b. Check claim status with the local BCBS carrier. Automatically refiling a claim when it does not have a response can cause duplicate claims to be filed to the insurance carrier. Chances are, if the carrier did not receive it the first time, the claim has an error and it needs to be reviewed or the provider has received a response and it has not been posted. Call the carrier and check claim status.

Timely filing requirements are: a. Always 1 year from the date of service. b. Determined by the payer. c. Unimportant. d. 30 days from date of service.

b. Determined by the payer. Each insurance company sets their own timely filing limits. It can also vary by different insurance plans within the same company.

The document reporting the benefits applied to a Blue Cross/Blue Shield claim is the: a. Explanation of Payment (EOP). b. Explanation of Benefits (EOB). c. Explanation of Coverage (EOC). d. None of the above.

b. Explanation of Benefits (EOB). Blue Cross/Blue Shield sends an Explanation of Benefits (EOB), to their covered members after they or other family members receive healthcare services to explain the status of a claim.

Tony's Blue Cross/Blue Shield healthcare insurance policy states that he must seek healthcare services only from providers that are part of a specific network. What type of Blue Cross/Blue Shield plan does Tony have? a. POS b. HMO c. Fee-for-Service d. Indemnity

b. HMO An HMO is a type of health benefits plan where members are required to receive healthcare services only from providers that are part of the HMO network.

Blue Cross/Blue Shield offers which type of Medicare plan? a. Medicare Plus b. Medicare Advantage c. Medicare Part G d. Medicare Add-on

b. Medicare Advantage Medicare is federally funded health insurance, typically for those aged 65 and over, or for people under 65 who are disabled or meet other special criteria. Blue Cross and Blue Shield offers a Medicare Advantage plan.

Carl has enrolled in a healthcare insurance plan that allows him to choose to have services provided within the Blue Cross/Blue Shield network or outside of the network. What type of plan best describes Carl's insurance coverage? a. Indemnity b. Point of Service c. Health Maintenance Organization (HMO) d. Preferred Provider Organization (PPO)

b. Point of Service Point-of-Service coverage is a healthcare option that allows members to choose medical services as needed and whether they will go to a provider within the Blue Cross and Blue Shield network or seek medical care outside of the network.

Blue Cross/Blue Shield received a claim on 4/15/19 for services performed on 3/15/18. The claim would be denied because: a. the claim did not have correct provider number. b. claim was filed after the timely filing limit. c. service was not a covered benefit. d. service did not meet medical necessity.

b. claim was filed after the timely filing limit. Timely filing limit for Blue Cross/Blue Shield is one year from date of service.

Best practice to prevent receiving a denial due to coverage termination would be to: a. call each payer every month to ensure that each scheduled patient is still covered. b. verify coverage prior to the patient's scheduled appointment. c. verify coverage after the patient is seen by provider. d. contact each patient every month to verify insurance coverage.

b. verify coverage prior to the patient's scheduled appointment. A coverage termination denial occurs when the patient does not have coverage with the insurance payer. To prevent these types of denials it is important to verify coverage prior to the scheduled visit.

When a provider signs a contract to be a participating provider with an insurance payer they are agreeing to: a. Only see patients that are enrolled with that insurance company. b. Bill the patient for the total amount the insurance company does not pay. c. Accept the fee schedules set by the insurance company. d. All of the above.

c. Accept the fee schedules set by the insurance company. Participating providers sign contracts with the insurance companies they wish to participate with and agree to accept the fee schedules set by the insurance company. The physician then can only bill the patient their deductible or co-insurance. They cannot balance bill the patient the difference between what the company paid and what the physician billed.

Which of the following defines Point-of-Service coverage? a. Coverage that requires a patient to first see their PCP. b. Coverage that allows members to choose medical services only within the Blue Cross network. c. Coverage that allows members to choose medical services as needed within the BCBS network or seek medical care outside of the network. d. Coverage that reimburses employees for specific healthcare expenses.

c. Coverage that allows members to choose medical services as needed within the BCBS network or seek medical care outside of the network. Point-of-Service (POS) coverage is a healthcare option that allows members to choose medical services as needed, and whether they will go to a provider within the Blue Cross and Blue Shield network, or seek medical care outside of the network.

Which of the following is an account that is usually funded by the employee only and reimburses employees for specified expenses as they are incurred? a. HRA b. HSA c. FSA d. HMO

c. FSA An FSA is an account that reimburses employees for specified expenses as expenses are incurred. The funding for FSAs is usually through deductions from the employee's paychecks.

Which of the following statements is NOT correct regarding timely filing? a. Claims must be filed before the end of the timely filing limit. b. Each BCBS carrier sets their own timely filing limit. c. If the physician fails to send a claim during the timely filing limit the balance can be sent to the patient. d. The timely filing limit can vary from plan to plan within the same insurance company.

c. If the physician fails to send a claim during the timely filing limit the balance can be sent to the patient. Failure to meet the timely filing limit does not allow for the patient to be billed for this encounter.

Which type of insurance plan is a federal and state program that provides coverage to the low-income population? a. Medicare b. HMO c. Medicaid d. PPO

c. Medicaid Medicaid is a joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

A claim is submitted for a patient who suffered a fractured femur. The diagnosis code that was submitted is S82.401A, with the CPT® fracture care code 27230. Does the diagnosis code support medical necessity for the service provided? a. Yes, the diagnosis code supports the CPT® code billed. b. Yes, the procedure code is supported by the ICD-10-CM code. c. No, the diagnosis code does not support the CPT® fracture care code. d. A diagnosis code is not necessary when reporting CPT® codes.

c. No, the diagnosis code does not support the CPT® fracture care code. Medical necessity was not met because the diagnosis code reports fracture of the fibula, and CPT® code reports a fracture of the femur. When a diagnosis code is not submitted correctly, the information needs to be corrected and the corrected claim resubmitted.

Blue Cross/Blue Shield identifies the individual or employee who pays for healthcare insurance coverage as the: a. Member b. Group c. Subscriber d. Payer

c. Subscriber The subscriber is the person who pays for the health insurance or whose employment makes him or her eligible for group health insurance.

The term for the set payment that the member pays to the healthcare provider on the day of service is the: a. office visit fee. b. co-insurance. c. copay. d. co-signer.

c. copay. A copayment or copay is the set amount the insured member pays the healthcare provider on the day of service.

The process of reviewing and validating professional qualifications of healthcare providers applying to participate with an organization is known as: a. accreditation. b. endorsement. c. credentialing. d. certification.

c. credentialing. Providers who apply for participation with a payer organization must undergo a process of professional qualification review and validation known as credentialing

Blue Cross and Blue Shield is the: a. oldest and smallest family of health benefits companies in the United States. b. newest and largest family of health benefits companies in the United States. c. oldest and largest family of health benefits companies in the United States. d. only health insurance company promoting preferred provider organizations.

c. oldest and largest family of health benefits companies in the United States. Blue Cross and Blue Shield companies is the nation's oldest and largest family of health benefits companies. Nationwide, Blue Cross and Blue Shield has more than 96 percent of hospitals and 95 percent of professional providers contracted with them.

The liaison between Blue Cross/Blue Shield and the contracted provider community is known as the: a. Insurance Representative. b. Provider Representative. c. Provider Network Consultant. d. All of the above.

d. All of the above. An Insurance Representative, also called a Provider Representative or Provider Network Consultant, serves as the liaison between Blue Cross and Blue Shield and the contracted provider community.

What is the timely filing requirement for Blue Cross Blue Shield? a. 90 days b. 180 days c. Filed by December 31st d. Claim requirements differ between plans

d. Claim requirements differ between plans Claim filing requirements differ between the different Blue Cross/Blue Shield plans. Unless otherwise specified in the contract, the timely filing limit for Blue Cross/Blue Shield plans is one year from date of service.

What is the correct action when the three-character prefix is not appended to a BCBS identification number? a. Append the most common local prefix and file the claim. b. Append XXX as the prefix and file the claim. c. Append ZZZ as the prefix and file the claim. d. Look at the patient's BCBS card and append the appropriate prefix listed on the card.

d. Look at the patient's BCBS card and append the appropriate prefix listed on the card. The prefix of the member's identification number helps identify the BCBS home company and the plan. The insurance card should be viewed so the correct three-character prefix is appended.

When a patient presents for their appointment, insurance coverage should be verified and: a. a copy made of the front of the insurance card. b. a copy made of the back of the insurance card. c. a copy made of their driver's license or other form of ID. d.

d. a copy made of both the front and back of the member's insurance card. Obtaining a copy of an insurance card, front and back, is imperative. If the information is entered into the practice management system incorrectly or additional information is needed, it can be found on the insurance card.

Participating providers agree to: a. only treat patients who have insurance coverage. b. only treat patients with chronic conditions. c. only treat established patients. d. accept the fee schedules determined by the insurance company.

d. accept the fee schedules determined by the insurance company. Participating providers sign contracts with the insurance companies they wish to participate with and agree to accept the fee schedules set by the insurance company.

A health insurance plan that reimburses for healthcare services provided to members based on providers bills submitted after the services are rendered is known as: a. traditional insurance. b. fee-for-service. c. indemnity. d. all of the above.

d. all of the above. Indemnity, also known as traditional insurance or Fee-for-Service, is an insurance plan that reimburses for healthcare services provided to members based on provider's bills submitted after the services are rendered.

The Blue Cross/Blue Shield member's insurance card will list which of the following: a. provider's name. b. type of insurance. c. type of plan. d. both b & c.

d. both b & c. At the top of the card the type of insurance with the type of plan (such as PPO, HMO, POS, traditional, etc.) is listed.

The provider, hospital, or entity that agrees to provide healthcare services to an insurance plan's enrollees is a: a. contracted provider. b. pre-determined provider. c. service provider. d. participating provider.

d. participating provider. A participating provider is a healthcare provider, hospital, or entity that has agreed to provide healthcare services to an insurance plan's enrollees. A participating provider must be contracted with the insurance plan's network.

A patient's insurance member card is issued by: a. the physician's office. b. the employer. c. the state. d. the insurance company.

d. the insurance company. A Member Card is a card that the insurance company issues to each member to carry for identification.