Chapter 7 SB

Health plans can require providers to submit claim attachments in which of the following formats? Multiple select question. By telephone By email By fax Available on request at provider site By mail

By email By fax Available on request at provider site By mail

The current paper claim approved by the NUCC is called the _____ claim form. Multiple choice question. PMP-1500 HIPAA-837 CMS-1500 NC-10

CMS-1500

What does EPSDT stand for? Multiple choice question. Early and periodic screening, diagnosis, and treatment Early post-screening, diagnostic treatment Educated periodic screening, diagnosis, and testing Early and periodic screening, diagnosis, and testing

Early and periodic screening, diagnosis, and treatment

Which of the following items are identified in the Physician/Supplier part of the CMS-1500 claim form? (Select all that apply.) Multiple select question. Healthcare provider Patient insurance number Additional information to process the claim Insurance information Services performed

Healthcare provider Additional information to process the claim Services performed

`Where on the CMS-1500 claim form do you enter the billing provider's Employer Identification Number (EIN) or Social Security number? Multiple choice question. IN 22 IN 24D IN 25 IN 33

IN 25

In addition to the non-NPI ID of the referring provider, ordering provider, or other source put in IN 17a of the CMS-1500 claim form, what should also be reported above the dotted line on the left side of the box before the Other ID number is entered? State license number Qualifier Tax ID number Date of service

Qualifier

The items in the _____ information section of the CMS-1500 form identify the patient, the insured, and the health plan. Multiple choice question. patient guarantor health plan insurance

patient

The _____ is the person or organization that receives payment for the claim. Multiple choice question. participating provider rendering provider health plan pay-to provider

pay-to provider

When entering telephone numbers on claims what should NOT be used? Multiple select question. spaces dashes numbers parentheses

spaces dashes parentheses

What kind of technology is required to for a provider to submit claims directly? Multiple choice question. Microsoft Windows special Excel Word

special

HIPAA requires electronic transmission of claims except for practices that have fewer than _____ full-time or equivalent employees and never send any kind of electronic healthcare transactions. ten fifteen twenty-five twenty

ten

The _____ may affect the physician's pay, usually because of the payer's contract with the physician. type of specialty provider's gender diagnosis code length of time the provider has been licensed

type of specialty

A _____ is additional data in printed or electronic format sent to support a claim. Multiple choice question. service line attachment claim note claim attachment diagnosis code pointer

claim attachment

The majority of providers use _____ to send and receive data in correct EDI format. Multiple choice question. clearinghouses third-party payers insurance companies outside billers

clearinghouses

Item Number 17 on the CMS-1500 claim form should have the name and _____ of the professional who referred or ordered the services or supplies on the claim. credentials telephone number tax id number address

credentials

The HIPAA 837P claim contains many _____ that are essentially the same as those used to complete a CMS-1500; they are just organized in a different way. Multiple choice question. item characters diagnosis codes procedure codes data elements

data elements

Codes two, three, and four of the diagnosis code pointers may also be linked, in _________ level of importance regarding the patient's treatment, to the service line. Multiple choice question. declining highest increasing lower

declining

The payer information section of the HIPAA 837P claim contains information about the payer to whom the claim is going to be sent, called the _____. Multiple choice question. insurance payer subscriber destination payer guarantor

destination payer

Some payers offer online _____ to providers, which involves using an Internet-based service into which employees key the standard data elements. Multiple choice question. clearinghouses direct data entry claim attachments service line entry

direct data entry

In the carrier block of the CMS-1500 form, commas, periods, and other punctuation, except for the hyphen in a nine-digit Zip code, are _____ used in the address. Multiple choice question. never rarely always sometimes

never

The _____, called the Other ID number, of the referring provider, ordering provider, or other source is the payer-assigned unique identifier of the physician or other healthcare provider. NPI ID number non-NPI ID number provider number tax ID number

non-NPI ID number

The _____, called the Other ID number, of the referring provider, ordering provider, or other source is the payer-assigned unique identifier of the physician or other healthcare provider. provider number NPI ID number non-NPI ID number tax ID number

non-NPI ID number

At least ______ diagnosis code must be linked to the procedure code. Multiple choice question. three one two four

one

When completing Item Number 20 to bill for laboratory services, enter an X in Yes if the reported service was performed by an _____. Multiple choice question. outside laboratory in-house laboratory inpatient facility urgent care facility

outside laboratory

The data elements that are transmitted electronically are not seen physically as they would be on a ______ form. Multiple choice question. paper referral computer data entry

paper

For many years, the CMS-1500 was the universal physician health claim accepted by most payers, which was a red and black printed form that was typed or computer-generated and mailed to _____. Multiple choice question. payers payees healthcare practices the insured

payers

The _____ number refers to the payer-assigned number authorizing the service(s). provider referral insurance claim prior authorization provider identification

prior authorization

For each _____, an NPI number and possibly non-NPI numbers with the qualifiers must be reported on the HIPAA 837P claim. Multiple choice question. procedure code place of service provider patient

provider

What are prepared for transmission after all required data elements have been posted to the practice management program? Multiple choice question. Clearinghouses Procedures Codes Claims

Claims

What are claims called that are accepted for adjudication by payers? Multiple choice question. Voided claims Original claims Replacement claims Clean claims

Clean claims

What Item Number on the CMS-1500 form is used to enter the prior authorization number? Item Number 21 Item Number 20 Item Number 22 Item Number 23

Item Number 23

_____ means the code and original reference number assigned by the destination payer or receiver to indicate a previously submitted claim or encounter. Multiple choice question. Medicaid resubmission Medicare resubmission Medicare submission Medicaid submission

Medicaid resubmission

In addition to the Group Health Plan and Other types of insurance coverage choices found in Item Number 1 of the CMS-1500 form, which of the following are the specific government programs listed? (Select all that apply.) Social Services Medicare and Medicaid CHAMPVA Federal BCBS TRICARE FECA Black Lung

Medicare and Medicaid CHAMPVA TRICARE FECA Black Lung

Under HIPAA EDI transactions must move to which format for 837P claims to provide enough room for ICD-10-CM codes and for additional data? Multiple choice question. CMS-1500 5010A1 version 1500 version HCFA-1500

5010A1 version

When resubmitting a claim, you must enter a bill frequency code aligned left in the left-hand side of the field. Which of the following would be correct bill frequency codes to place in Item Number 22? (Select all that apply.) Multiple select question. 8 9 6 7

8 7

The HIPAA-mandated electronic transaction for claims from physicians and other medical professionals is the _____ Health Care Claim: Professional. a) HIPAA X13 838 b) HIPAA X12 838 c) HIPAA X12 837 d) HIPAA X13 837

c) HIPAA X12 837

The electronic HIPAA claim is based on the _____, which is a paper claim form. Multiple choice question. HIPAA-1500 CMA-1500 HCFA-1500 CMS-1500

CMS-1500

What is an important step to perform before claim transmittal? Multiple choice question. Check the claim. File the claim. Refile the claim. Call the insurance company.

Check the claim.

What number, unique for each claim, is assigned by the sender? Multiple choice question. Provider identification Patient identification Claim identifier Claim control

Claim control

What are editing software programs called that make sure that all required fields are filled and only valid codes are used, and perform other checks? Multiple choice question. Clean claims Clearinghouses Claim scrubbers Direct data

Claim scrubbers

Which Item Numbers on the CMS-1500 claim form contain information about the provider and the patient's condition, including the diagnoses, procedures, and charges? Multiple choice question. Item Numbers 1 through 33 Item Numbers 14 through 33 Item Numbers 1 through 13 Item Numbers 14 through 31

Item Numbers 14 through 33

What involves using an Internet-based service into which employees key the standard data elements? Multiple choice question. POS NPI DDI DDE

DDE

When entering the pregnancy date in Item Number 14 of the CMS-1500 claim form, what date is used? Multiple choice question. Date of the injury Date of the last pregnancy Date of the last menstrual period (LMP) Date of the current illness

Date of the last menstrual period (LMP)

The dates entered in Item Number 16 of the CMS-1500 claim form represent which of the following? Dates of the patient's unemployment Dates the employed patient is unable to work in his or her current occupation Dates the unemployed patient is unable to work in his or her current occupation Dates of the patient's hospitalization

Dates the employed patient is unable to work in his or her current occupation

What are some data entry tips for submission of clean claims? Multiple select question. Do not check with payers for exceptions to the guidelines. Do not use special characters unless required by the carrier. Only enter numbers in the ZIP code field Do not use prefixes for people's names

Do not use special characters unless required by the carrier. Only enter numbers in the ZIP code field Do not use prefixes for people's names

PMP vendors are responsible for which of the following? Multiple select question. Processing CMS-1500 claims for submission and claim tracking Keeping their software products up to date Receiving certification from HIPAA testing vendors that their software can accommodate HIPAA-mandated transactions Training office personnel in the use of new features

Keeping their software products up to date Receiving certification from HIPAA testing vendors that their software can accommodate HIPAA-mandated transactions Training office personnel in the use of new features

The Item Number for EPSDT Family Plan refers to some services that may be covered under state _____ plans. Multiple choice question. Medicare private payer Medicaid TRICARE

Medicaid

The date entered in Item Number 14 of the CMS-1500 claim form refers to which of the following dates about the patient? (Select all that apply.) First date of onset of illness Date of service LMP for pregnancy Date of birth Actual date of injury

First date of onset of illness LMP for pregnancy Actual date of injury

If the patient has group contract insurance with a private payer, which type of insurance is selected in Item Number 1 of the CMS-1500 form? No selection Other Private Group Health Plan

Group Health Plan

The organization of the data elements on the _____ is efficient for electronic transmission rather than for use on a paper form. HIPAA 837P Claim CMS-1500 Claim Medicaid Claim ICD-10-CM

HIPAA 837P Claim

To transmit claims directly what must a provider supply? Multiple choice question. clearinghouse standards content of each IN or data element HIPAA data elements telephone lines to transmit

HIPAA data elements

Which of the following pieces of information are included in the patient information section of the CMS-1500 claim form? (Select all that apply.) Procedure information Health plan's information Patient information Insured's information Code linkage

Health plan's information Patient information Insured's information

Where on the CMS-1500 claim form do you enter the patient's account number that is used by the practice's accounting system? IN 24 IN 26 IN 27 IN 25

IN 26

What Item Number of the CMS-1500 claim form is used to enter the date of whether the patient previously had a related condition? Item Number 3 Item Number 16 Item Number 14 Item Number 15

Item Number 15

What Item Number on the CMS-1500 claim form refers to the time span the patient is or was unable to work? Multiple choice question. Item Number 16 Item Number 15 Item Number 17 Item Number 14

Item Number 16

What Item Number on the CMS-1500 claim form gives the name of the referring or ordering provider if the service or item was ordered or referred by a provider? Multiple choice question. Item Number 17 Item Number 17c Item Number 17a Item Number 17b

Item Number 17

What Item Number is used to refer to an inpatient stay and indicate the admission and discharge dates associated with the service(s) on the claim? Multiple choice question. Item Number 18: Hospitalization Dates Related to Current Services Item Number 16: Dates Patient Unable to Work in Current Occupation Item Number 17: Hospitalization Dates Related to Current Services Item Number 14: Date of Current Illness, Injury, or Pregnancy (LMP)

Item Number 18: Hospitalization Dates Related to Current Services

What Item Number on the CMS-1500 claim form is used to report additional claim information? Item Number 19 Item Number 20 Item Number 22 Item Number 21

Item Number 19

Which Item Number on the CMS-1500 claim form records the insurance identification number that appears on the insurance card of the policyholder, who may or may not be the patient? Multiple choice question. Item Number 1a Item Number 1b Item Number 1c Item Number 1d

Item Number 1a

Which Item Number is used to report outside lab charges to show that services have been rendered by an independent provider, as indicated in IN 32, and to list the related costs? Item Number 21 Item Number 22 Item Number 19 Item Number 20

Item Number 20

Which of the following are among the most common errors on claims? Multiple select question. Using valid procedure codes Patient's marital status missing on claim Missing or invalid patient birth date Missing part of the name or the identifier of the referring provider

Missing or invalid patient birth date Missing part of the name or the identifier of the referring provider

The organization responsible for claim content is abbreviated as _____. Multiple choice question. AHIMA CMS HIPAANCC NUCC

NUCC

What committee is responsible for modifying the instructions for the CMS-1500 to bring it in more accord with the electronic claim without having to change the overall layout? NICC NCUC NUCC NUCU

NUCC

Match each payer responsibility sequence number code to its meaning. P S T

P - primary payer S - secondary payer T - tertiary payer

What kind of vendors are responsible for keeping their software products up to date? Multiple choice question. POS NPI CPT PMP

PMP

Most _____ provide a way for the medical insurance specialist to review claims for accuracy and to create a record of claims that are about to be sent. Multiple choice question. CPTs PMPs NPIs PIPs

PMPs

What information is used primarily to help identify patients and post payments when working with remittance advices? Patient's Social Security number Patient's NPI Patient's insurance number used by the health plan Patient's account number used by the practice's accounting system

Patient's account number used by the practice's accounting system

Like the CMS-1500, the HIPAA 837P claim requires data on which of the following types of providers? (Select all that apply.) Pay-to provider Billing provider Participating provider Referring provider Rendering provider

Pay-to provider Billing provider Referring provider Rendering provider

Which part of the CMS-1500 claim form identifies the healthcare provider, describes the services performed, and gives the payer additional information to process the claim? Patient's information section Insurance company information section Physician/supplier information section Insured's information section

Physician/supplier information section

If applicable, who is reported as the entity or person other than the subscriber or patient who has financial responsibility for the bill? Policyholder Responsible party Subscriber Dependent

Responsible party

Which of the following types of IDs can be entered in IN 25: Federal Tax ID Number for the billing provider from IN 25? (Select all that apply.) Multiple select question. NPI POS SSN EIN

SSN EIN

What term is used on the HIPAA 837P for the insurance policyholder or guarantor, meaning the same as the insured on the CMS-1500 claim? Multiple choice question. Prescriber Guardian Subscriber Insured

Subscriber

IN 19 may be used to report _____, using the qualifier PKW followed by a report-type code, a transmission-type code, and an attachment control. Multiple choice question. Supplemental Claim Information diagnostic code information outside lab information procedural code information

Supplemental Claim Information

What code is a ten-digit number that stands for a physician's medical specialty? Multiple choice question. CPT Place of Service Taxonomy ICD

Taxonomy

In Item Number 18 of the CMS-1500 claim form, how are the dates entered for patients still hospitalized? The admission date is left blank in the From box, and the discharge date is entered in the To box. The admission date is listed in the From box, and the To box is left blank. The admission and discharge dates are left blank. The admission date is listed in the From box, and the discharge date is in the To box.

The admission date is listed in the From box, and the To box is left blank.

The insured's ID number is the identification number for which of the following? (Select all that apply.) The provider who participates The one who holds the policy The dependent patient with their own unique identifier The dependent patient without their own unique identifier

The one who holds the policy The dependent patient with their own unique identifier

The CMS-1500 claim has a carrier block and how many Item Numbers (INs)? Multiple choice question. Thirty-two Thirty-four Thirty-three Thirty-one

Thirty-three

What is the maximum number of characters used for the claim control number? Multiple choice question. Nine Seven Ten Twenty

Twenty

Where is the carrier block located on the CMS-1500? Multiple choice question. Upper left portion Lower right portion Lower left portion Upper right portion

Upper right portion

What does Other Date in Item Number 15 of the CMS-1500 claim form represent? Whether the patient has other insurance Whether the patient was previously pregnant Whether the patient previously had a related condition Whether the patient was previously married

Whether the patient previously had a related condition

The _____ provider is a physician or other entity, such as a lab, that has provided the care. participating pay-to rendering billing

rendering