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
