Chapter 7 - Healthcare Claim Preparation and Transmission

What can users do to stay up-to-date with the CMS-1500? A. check the NUCC website for updated instructions B. check the AMA website for updated instructions C. contact the contracted payers D. contact Medicare and Medicaid

check the NUCC website for updated instructions

Identify the important step that immediately proceeds claim transmittal. A. checking the claim B. notifying the payer C. getting patient approval D. notifying the patient

checking the claim

On a HIPAA claim, determine which of the following is assigned to a claim by the sender. A. claim control number and line item number B. line item control number only C. claim control number only D. claim control number and claim submission reason code

claim control number and line item number

Choose the editing software programs used to check claims for error correction. A. claim scrubbers B. clearinghouses C. claim transmitters D. claim checkers

claim scrubbers

Claims that are acceptable for adjudication by payers are called A. standard claims B. simple claims C. clean claims D. clear claims

clean claims

What is the most common method of claim transmission? A. the adjudication process B. direct transmission to the payer C. clearinghouse use D. direct data entry

clearinghouse use

In which of these methods of transmitting claims can employees key standard data elements using an Internet-based service? A. the adjudication process B. direct transmission to the payer C. clearinghouse use D. direct data entry

direct data entry

In which of these methods of transmitting claims do providers and payers exchange transactions directly without using a clearinghouse? A. the adjudication process B. direct transmission to the payer C. clearinghouse use D. direct data entry

direct transmission to the payer

In which format can claim attachments be sent? A. electronic format only B. paper format only C. electronic or paper format D. claim attachments cannot be sent with the claim

electronic or paper format

Which of the following payers usually do not require additional data elements? A. EPSDT/Medicaid claims B. Medicare claims C. workers' compensation and disability claims D. fee for service claims

fee for service claims

How many diagnosis pointers can be listed per service line according to the NUCC manual? A. one B. two C. four D. six

four

The insured's ID number is the A. identification number of the policy holder B. physician's NPI C. payer's identification number D. physician's legacy number

identification number of the policy holder *Item Number 1a records the insurance identification number that appears on the insurance card of the person who holds the policy, who may or may not be the patient.

Identify the information included in blocks 1 through 13 of the CMS-1500. A. information about the provider B. information about the patient's condition C. information about the patient and the patient's insurance coverage D. information about the diagnoses, procedures, and charges

information about the patient and the patient's insurance coverage

Which of the following skills are required of medical insurance specialists in completing claims? A. organizational skills & good thinking skills B. critical thinking skills & A/P C. memorization D. medical terminology and memorization

organizational skills & good thinking skills

Which one of these is not considered to be a common error in generating claims? A. missing patient date of birth B. incomplete other payer information C. invalid procedure codes D. patient name

patient name

Which of the following pieces of information are included in the patient information section of the CMS-1500? A. diagnosis B. patient's relationship to insured C. procedure D. hospitalization dates

patient's relationship to insured

Which of the following codes could be used to indicate that a procedure took place in a medical office? A. administrative codes B. taxonomy codes C. place of service codes D. diagnosis codes

place of service codes Place of service (POS) codes describe the location where the service is provided

What is recorded in Section 24 of CMS-1500? A. patient's address B. procedures performed for a patient C. referring physician D. rendering physician

procedures performed for a patient

Section 24 of the CMS-1500 records service line information, which contains the A. diagnoses made by the physician B. procedures performed for the patient C. patient's name and address D. referring provider NPI number

procedures performed for the patient

You are reporting an unlisted procedure code that requires a very lengthy narrative description. Determine the best way to present this information to the payer. A. write part of the description in Item Number 19 as space allows B. provide a special report C. write a description in the margin of the CMS-1500 claim form D. wait until information is requested from the payer

provide a special report *When reporting an unlisted procedure, include a narrative description in Item Number 19 if a coherent description can be given within the confines of that box; otherwise, an attachment must be submitted with the claim.

What are the five sections on a claim? A. provider, clearinghouse, payer, claim details, diagnosis B. provider, claim details, diagnosis, procedure, payer C. provider, payer, diagnosis, clearinghouse, subscriber D. provider, subscriber, payer, claim details, services

provider, subscriber, payer, claim details, services

What character should be used in Item Number 24F if the encounter was under an MCO capitation contract? A. C B. 0 C. $ D. both C and 0

0

. Identify the claim filing indicator code that is used to indicate a self-pay patient. A. 09 B. 10 C. 11 D. 12

09

The electronic transmission of claims is not required by law if a practice never sends any kind of electronic healthcare transactions, and has less than __________ full-time or equivalent employees. A. five B. ten C. twenty D. fifty

10 HIPAA requires electronic transmission of claims, except for practices that have less than ten full-time or equivalent employees and never send any kind of electronic healthcare transactions

. Determine which of the following may be a qualifier. A. 2375742157 B. 17a C. 1B D. 1HA

1B A qualifier is a two-digit code for a type of provider identification number other than the NPI

Name the POS code used to indicate a procedure occurred in an outpatient hospital. A. 21 B. 22 C. 23 D. 24

22

What is sent as additional data to support a claim? A. PHI B. attachment C. procedure code D. National Uniform Claim Committee number

attachment Claim attachments, such as lab results or discharge notes, are sent either in printed or electronic format to support a claim

Name the POS code used to indicate a procedure occurred in a skilled nursing facility. A. 11 B. 12 C. 31 D. 81

31

A billing service sending a claim is likely to be the: A. destination payer B. referring provider C. billing provider D. pay-to provider

billing provider

Where is the carrier block located on the CMS-1500? A. upper left B. upper right C. bottom left D. bottom right

The carrier block is located on the upper right of the CMS-1500.

Name the HIPAA transaction for electronic claims that was generated by physicians. A. 837 P B. 847 P C. 837 I D. 847 I

837 P

Name the HIPAA transaction for electronic claims that were generated by hospitals. A. 837P B. 847P C. 837I D. 847I

847I

What does a claim filing indicator code identify? A. the physician's diagnosis B. the procedures that were performed C. the name of the health plan D. the type of health plan

A claim filing indicator code is an administrative code used to identify the type of health plan, such as a PPO

Determine where you would report a service that was performed by an outside laboratory on the CMS-1500. A. Item Number 19 B. Item Number 20 C. Item Number 21 D. Item Number 22

An X in the "Yes" box of Item Number 20 indicates that the reported service was performed by an outside laboratory

Physicians identify their medical specialty by using: A. administrative codes B. taxonomy codes C. place of service codes D. diagnosis codes

A taxonomy code (a ten-digit number that stands for a physician's medical specialty)

When the patient and insured are not the same person, what type of code is required to indicate this fact? A. data element code B. diagnosis code C. individual relationship code D. NRUC code

An individual relationship code is needed when the patient and the insured are not the same person.

Name the current paper claim approved by the NUCC. A. CMS-1500 B. CMS-1500 (08/05) C. 837 D. HIPAA 837 claim

CMS-1500 (08/05)

What choice may be made in Item Number 6 to show that the insured is the patient? A. Self B. Spouse C. Child D. Other

Choosing "Self" in Item Number 6 indicates that the insured is the patient.

. You are completing a CMS-1500 and realize that a husband has additional coverage under his wife's policy. Determine where you would record the wife's name on the CMS-1500 for the additional insurance. A. Item Number 8 B. Item Number 9 C. Item Numbers 10a-10c D. Item Number 11d

Item Number 9 An entry in the other insured's name box (Item Number 9) indicates that there is a holder of another policy that may cover the patient

Identify the claim filing indicator code that is used to indicate that the health plan is Medicaid. A. AM B. MB C. MC D. OF

MC

A HIPAA-mandated electronic transaction for claims may also be called? A. CMS1500 B. HIPAA X12 837 Health Care Claim or Equivalent Encounter Information C. HCFA1500 D. EDI

HIPAA X12 837 Health Care Claim or Equivalent The HIPAA-mandated electronic transaction for claims is the HIPAA X12 837 Health Care Claim or Equivalent Encounter Information, and is usually called the "837 claim" or the "HIPAA claim."

How many different types of providers may need to be identified? A. two B. three C. four D. five

It may be necessary to identify four different types of providers.

You are working at a practice and need to decide whether or not you may release a medical document about a patient in order to process a claim. Determine where to find this information on the CMS-1500. A. Item Number 8 B. Item Number 9 C. Item Number 12 D. Item Number 13

Item Number 12 is used to indicate that there is an authorization on file for the release of any medical or other information necessary to process and/or adjudicate the claim

Name the qualifier used to indicate a provider plan network identification number. A. G2 B. N5 C. X5 D. ZZ

N5

You are working for a practice and need to include a data element on a claim because it is required by the contract with the payer. Determine which of the following data element types need be included in regard to this situation. A. R B. NRUC C. RIA D. NR

NRUC data elements are required only when they are part of a contract between a provider and a payer or when they are specified by state or federal legislation or regulations

The provider who provides the procedure on a claim other than the pay-to provider is called the A. referring provider B. rendering provider C. billing provider D. primary provider

Rendering provider

. What is the payer's responsibility sequence number for the payer of last resort? A. P B. L C. S D. T

T

Which describes the meaning of transaction "837P"? A. hospital B. any provider C. professional D. Insurance Companies

The 837P is the Health Care Claim: professional.

You need to send a claim to a payer who does not accept electronic claims. Identify the claim form you would use to send a paper claim. A. 837 claim B. CMS-1500 claim C. HIPAA claim D. EDI claim

The CMS-1500 is the paper claim for physician services.

How many diagnosis codes may be reported on the HIPAA 837? A. four B. six C. eight D. twelve

The HIPAA 837 permits up to twelve diagnosis codes to be reported.

Name the electronic format that practices use to ask payers about claims. A. HIPAA X12 837 B. HIPAA X12 276/277 C. CMS-1500 D. HIPAA claim

The HIPAA X12 276/277 Health Care Claim Status Inquiry/Response is the electronic format used to ask payers about claims

What organization determines the content of both HIPAA 837 and CMS-1500 claims? A. NUCC B. HIPAA C. NPI D. CMS

The National Uniform Claim Committee (NUCC) determines the content of both HIPAA 837 and CMS-1500 claims.

Name the function of the carrier block. A. it allows the payer to input their own codes B. it allows the payer to make notes C. it allows for a four-line address for the payer D. it allows for a four-line address for the patient

The carrier block allows for a four-line address for the payer

You are working at a medical practice and have been requested to resubmit a claim to replace one that was sent the previous week. Determine what claim frequency code should be applied to the claim. A. 1 B. 7 C. 8 D. no frequency code is required

The claim frequency code 7 should be used if an original claim is being replaced with a new claim.

Name the condition code you would apply to an abortion performed due to social or economic reasons. A. AE B. AF C. AG D. AH

The condition code AG is used for an abortion due to social or economic reasons

Explain the purpose of Item Number 10a -10C on the CMS-1500. A. to determine liability for the condition B. to determine the need for additional services C. to determine the patient's availability for appointments D. this field is not required

The information in Item Number 10a - 10c is important for determination of liability and coordination of benefits

You are working at a practice and need to submit a claim, but cannot reach a patient to get their address, which is not on file. Demonstrate the procedure you should follow. A. submit the claim with the patient's address left blank B. submit the claim with "Unknown" entered for the patient's address C. submit the claim using the practice's address in place of the patient's address D. do not submit the claim until you are able to retrieve the patient's address

The patient's address is a required data element, so "Unknown" should be entered if the address is not known

How many major methods are there for transmitting claims electronically? A. one B. two C. three D. four

There are three major methods of transmitting claims electronically: direct transmission to the payer, clearinghouse use, and direct data entry

What type of signatures should usually be used in Item Number 31? A. facsimiles or original written or electronic messages B. electronic signatures C. stamped signatures D. no signature required; leave blank

This feature no longer exists, leave blank.

HIPAA EDI transactions are sent via: A. 4010 version B. 5010 version C. any version D. payer's version

Under HIPAA, as of 2012, EDI transactions must move to the 5010 version

How many of the diagnosis codes reported on the HIPAA 837 may be linked to each reported procedure? A. one B. four C. six D. eight

Up to four of the diagnosis codes reported on the HIPAA 837 may be linked to each procedure that is reported

A payer requires the provider to list specific identifiers on the CMS-1500. Determine the most likely place they would require this information to be reported. A. Item Number 19 B. Item Number 20 C. Item Number 22 D. Item Number 24

Users should refer to instructions from the applicable public or private payer regarding the use of Item Number 19

When entering data for a claim, do NOT A. use prefixes for people's names or use hyphens in telephone numbers B. use a dash, space, or special character in a Zip code field C. use hyphens, dashes, spaces, special characters, or parentheses in telephone numbers D. use hyphens in telephone numbers, use prefixes in people's name, use a dash in zip code

When entering data for a claim, do not use prefixes for people's names, use a dash, space, or special character in a Zip code field, or use hyphens, dashes, spaces, special characters, or parentheses in telephone numbers

Which of the following benefits do medical insurance specialists gain by becoming familiar with the information most often required on claims their practice prepares? A. learning anatomy and physiology B. ability to respond to payers' questions C. ability to memorize a set claim completion process D. learning medical terminology

ability to respond to payers' questions

Name the qualifier used to indicate a provider's taxonomy number. A. G2 B. N5 C. X5 D. ZZ

ZZ

Examine the following entities and determine which may act as a billing provider. A. only a clearinghouse and practice B. only a practice and billing service C. only a billing service and clearinghouse D. a clearinghouse, practice, and billing service

a clearinghouse, practice, and billing service

On a HIPAA claim, which of the following is assigned to a particular service being reported? A. a claim control number B. a line item control number C. either claim control number or line item control number D. neither claim control number nor line item control number

a line item control number

Describe the circumstances under which the last-seen date is not required to be reported on the HIPAA 837 claim. A. the timing and/or frequency of visits affects payment for services B. a claim involves an independent physical therapist's or occupational therapist's services C. a physician's services involving routine foot care D. the original date seen

a physician's services involving routine foot care

What type of code may not be required by HIPAA, but if used, must be chosen from the NUCC list? A. administrative codes B. taxonomy codes C. place of service codes D. diagnosis codes

administrative codes Although the use of administrative code sets is not required by HIPAA, if you choose to report one, it must be on the NUCC list

Determine what was not required of PMP vendors when the HIPAA 837 electronic transaction was mandated. A. receiving certification from HIPAA testing vendors that their software can accommodate HIPAA-mandated transactions B. training office personnel in the use of new features C. maintaining up-to-date software products D. providing updates at no additional cost

providing updates at no additional cost PMP vendors are responsible for (1) keeping their software products up to date, (2) receiving certification from HIPAA testing vendors that their software can accommodate HIPAA-mandated transactions, and (3) training office personnel in the use of new feature

A legacy (non-NPI) ID number has two parts, the number itself as well as a(n) A. qualifier B. other ID number C. taxonomy code D. claim control number

qualifier

If a patient was sent by another physician, that physician is known as the A. referring physician B. pay to provider C. rendering physician D. billing provider

referring physician If another physician sent the patient, they need to be identified as the referring or ordering physician.

Under HIPAA, payers may not. A. refuse to accept the standard transactions B. restrict what clearinghouse used C. restrict what the PMP office uses D. delay payment of a non-compliant claims

refuse to accept the standard transactions

The physician who actually provided the service is the A. destination payer B. rendering provider C. billing provider D. pay-to provider

rendering provider

A data element that HIPAA always mandates reporting is called a(n) A. not required data element B. NRUC data element C. required data element D. situational data element

required data element

What is the terminology used when the provider must supply the data element on every claim? A. required data element B. required if applicable data element C. not required unless specified under contract data element D. not required data element

required data element

When nonspecific procedure codes such as unlisted CPT codes are used, the claim must contain: A. extra diagnosis codes B. modifiers C. service-line level description of the work or drug/dosage D. attachments

service-line level description of the work or drug/dosage

A data element that HIPAA mandates reporting under certain conditions is called a(n): A. not required data element B. NRUC data element C. required data element D. situational data element

situational data element

Explain the reason why the five levels of the HIPAA 837 are set up as a hierarchy. A. in order to conform with the order that payers demand the information to be transmitted B. so that the most important information on the HIPAA 837 appears first C. so that when the claim is sent electronically, the only data elements that have to be sent are those that do not repeat previous data. D. none of these are correct

so that when the claim is sent electronically, the only data elements that have to be sent are those that do not repeat previous data.

Which of the following is a data element that is required on the HIPAA 837 claim? A. the insured's marital status and gender B. the physician's signature C. the balance due D. the billing provider name and telephone number

the billing provider name and telephone number

What item is not included in the patient information section of the CMS-1500? A. the insured B. the patient C. the health plan D. the diagnosis

the diagnosis

The responsible party is held accountable for: A. the correct assignment of codes B. the correct completion of the HIPAA 837 C. the financial responsibility for a bill D. the submission of the electronic claim

the financial responsibility for a bill

What entity is the destination payer? A. the patient who is receiving a payment from a health plan B. the provider that is receiving a payment from a health plan C. the health plan receiving a HIPAA claim D. the provider who is seeing the patient

the health plan receiving a HIPAA claim

Using the process of DDE, claims are loaded directly into A. the health plans' computers B. the practices' computers C. the clearinghouses' computers D. the practice management program

the health plans' computers

Why has sending paper claims become less common? A. the increases in the prices of paper and the mail B. patients began requesting the use of less paper claims C. the increased use of information technology D. insurance companies do not require claims to be submitted

the increased use of information technology

What information about an accident is not required to be reported on the HIPAA 837 claim? A. the state or country in which the accident occurred B. the type of accident C. the date and time of the accident D. the name of the person who caused the accident

the name of the person who caused the accident

When the subscriber and the patient are the same person, what patient data is required on the HIPAA 837? A. the information must be duplicated in both sections B. the subscriber data is not required if the subscribed and the patient are the same C. the patient data is not required if the subscribed and the patient are the same D. none of these are correct; the subscriber and the patient cannot be the same If the subscriber and the patient are the same, then the patient data is not needed on the HIPAA 837

the patient data is not required if the subscribed and the patient are the same

Identify what is indicated by an individual relationship code. A. the patient's relationship to the insured B. the insured's relationship to the patient C. the insured's insurance plan D. the patient's relationship to the provider

the patient's relationship to the insured

Identify the person or organization that receives payment. A. the destination payer B. the referring provider C. the billing provider D. the pay-to provider

the pay-to provider

Under HIPAA, what may happen if the required data elements are not transmitted? A. the practice may lose its license B. the payer may reject the claim C. the medical insurance specialist may be prosecuted by law D. the practice can face penalties and fines

the payer may reject the claim

Explain how a payer will respond to a claim that does not contain an ICD-9 (or -10)-CM code. A. the payer will deny the claim B. the payer will provide the code they deem most appropriate C. the payer will call the practice and ask for the code D. none of these are correct

the payer will deny the claim A claim that does not report at least one diagnosis code will be denied

. What information might be recorded in Item Number 25? A. the physicians NPI number B. the referring physicians NPI number C. the physician's or supplier's EIN or SSN D. the legacy number

the physician's or supplier's EIN or SSN

Describe the reason for and the process of "dropping to paper." A. the practice can no longer afford to submit claims electronically and reverts to sending the CMS-1500 paper claim B. the practice prints and sends the CMS-1500 paper claim because the payer has not acknowledged receipt of it via electronic transmission C. the practice sends the payer a CMS-1500 paper claim in addition to an electronic claim to make the process easier for the payer D. all of these are correct

the practice prints and sends the CMS-1500 paper claim because the payer has not acknowledged receipt of it via electronic transmission

Assume that three providers are indicated for a claim for lab services. A clearinghouse is the billing provider and the physician practice is the pay-to provider. What type of provider is the laboratory? A. the rendering provider B. the referring provider C. the model provider D. the destination provider

the rendering provider

Name the data element that is required for use on the HIPAA 837P in conjunction with CMS Item Number 30. A. Total Claim Charge Amount B. Patient Paid Amount C. Laboratory or Facility Information D. this data element is "NOT USED"

this data element is "NOT USED"

Discuss the purpose of the shading in the top portions for the six service lines in Section 24 of the CMS-1500 claim form. A. to allow the billing of twelve lines of service B. to allow the provider to input notes C. to allow the payer to input notes D. to allow for six lines of service

to allow for six lines of service

Correct medical code sets for claims are those that are A. valid at the time the service is provided B. valid at the time the claim is prepared C. valid at the time the claim is electronically sent D. valid at the time the claim is appealed

valid at the time the service is provided

Correct medical code sets are those that are: A. valid when the claim is processed B. valid when the claim is paid C. valid based on payers guidelines D. valid at the time the service was performed

valid at the time the service was performed

Correct administrative code sets for claims are those that are A. valid at the time the transaction is started B. valid at the time the transaction has ended C. valid only if sent electronically D. valid only if it is necessary to appeal the claim

valid at the time the transaction is started

How current must the signature on file have been obtained for the release of information to be permissible? A. within six months B. within twelve months C. within two years D. within three years

within twelve months If a release of information is required, then the release on file must be current (signed within the last twelve months).