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Questions and Answers
The phrase _____ was coined to indicate payment of services rendered by someone other than the patient.
The phrase _____ was coined to indicate payment of services rendered by someone other than the patient.
Third-party reimbursement
Since 2005, providers have been urged to:
Since 2005, providers have been urged to:
Send claims electronically
The CMS-1500 form is accepted by:
The CMS-1500 form is accepted by:
Both Medicare and Medicaid
When a third-party payer identifies an error on the claim form, the claim is:
When a third-party payer identifies an error on the claim form, the claim is:
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How many digits are in a National Provider Identifier (NPI) number?
How many digits are in a National Provider Identifier (NPI) number?
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What is the first step in completing a claim form?
What is the first step in completing a claim form?
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Electronically processing claim forms to insurance carriers:
Electronically processing claim forms to insurance carriers:
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Which form is also known as the UB-04 form?
Which form is also known as the UB-04 form?
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Which of the following is not a fee usually charged by a clearinghouse?
Which of the following is not a fee usually charged by a clearinghouse?
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Which of the following is not an advantage of using an Electronic Claims Tracking (ECT) system?
Which of the following is not an advantage of using an Electronic Claims Tracking (ECT) system?
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Manual claims tracking:
Manual claims tracking:
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When following up on a delinquent claim, if the carrier tells you that it is still in process, you should:
When following up on a delinquent claim, if the carrier tells you that it is still in process, you should:
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When applying an insurance adjustment to a patient's account, you are not typically required to post the:
When applying an insurance adjustment to a patient's account, you are not typically required to post the:
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- Number that identifies or refers to the claim that either the patient or the health provider submitted to the insurance company.
- Number that identifies or refers to the claim that either the patient or the health provider submitted to the insurance company.
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- Beginning and end dates of the health-related service a patient received from a provider.
- Beginning and end dates of the health-related service a patient received from a provider.
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- Amount of money that a patient's insurance company did not pay the provider.
- Amount of money that a patient's insurance company did not pay the provider.
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Amount of money a patient owes as a share of the bill.
Amount of money a patient owes as a share of the bill.
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Amount a provider billed the patient's insurance company for a service.
Amount a provider billed the patient's insurance company for a service.
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Number assigned to a patient by the insurance company, which should match the number on the patient's insurance card.
Number assigned to a patient by the insurance company, which should match the number on the patient's insurance card.
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- Code and brief description of the health-related service a patient received from a provider.
- Code and brief description of the health-related service a patient received from a provider.
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Name of the person who received the service.
Name of the person who received the service.
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- Authorizes benefits to be paid directly from a third-party payer to a provider.
- Authorizes benefits to be paid directly from a third-party payer to a provider.
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- Standard claim form used for billing in medical offices.
- Standard claim form used for billing in medical offices.
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- Book in which a list of insurance claims is kept.
- Book in which a list of insurance claims is kept.
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- Type of payment used for centuries in the past.
- Type of payment used for centuries in the past.
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- This must be completed before submitting electronic media claims to Medicare.
- This must be completed before submitting electronic media claims to Medicare.
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- In many instances, this will pay most, if not all, of the balance left over from the primary insurance to your physician and will leave little out-of-pocket expenses for the patient.
- In many instances, this will pay most, if not all, of the balance left over from the primary insurance to your physician and will leave little out-of-pocket expenses for the patient.
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Patient's signature on a form that permits the release of his or her information, allowing the claim to be filed on his or her behalf.
Patient's signature on a form that permits the release of his or her information, allowing the claim to be filed on his or her behalf.
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Use of these allows a medical facility or provider's office to submit transactions faster and be paid sooner.
Use of these allows a medical facility or provider's office to submit transactions faster and be paid sooner.
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Form or document that may be sent to the patient by their insurance company after they have had a health care service that was paid by the insurance company (may take up to several months to receive).
Form or document that may be sent to the patient by their insurance company after they have had a health care service that was paid by the insurance company (may take up to several months to receive).
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- Developed to report the health care provided to the source of payment when third-party reimbursement was created.
- Developed to report the health care provided to the source of payment when third-party reimbursement was created.
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- Private or public company that often serves as the middleman between providers and billing groups, payers, and other health care partners for the transmission and translation of electronic claims information into the specific format required by payers.
- Private or public company that often serves as the middleman between providers and billing groups, payers, and other health care partners for the transmission and translation of electronic claims information into the specific format required by payers.
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This amount is posted from the insurance payment or insurance adjustment.
This amount is posted from the insurance payment or insurance adjustment.
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- Paper claim form that may be submitted by an institutional provider that meets certain requirements.
- Paper claim form that may be submitted by an institutional provider that meets certain requirements.
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- Sets forth the very specific requirements a provider must meet in order to submit paper claim forms and receive CMS payment.
- Sets forth the very specific requirements a provider must meet in order to submit paper claim forms and receive CMS payment.
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- The most common of these are federal and state agencies, insurance companies, and workers' compensation.
- The most common of these are federal and state agencies, insurance companies, and workers' compensation.
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Similar to the EOB but is the document provided by the payer to the provider.
Similar to the EOB but is the document provided by the payer to the provider.
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These give you immediate access to the status of a claim or group of claims.
These give you immediate access to the status of a claim or group of claims.
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Information required to file a third-party claim on the CMS-1500 form includes all but:
Information required to file a third-party claim on the CMS-1500 form includes all but:
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The steps to file a third-party claim and accurately complete the CMS-1500 form include:
The steps to file a third-party claim and accurately complete the CMS-1500 form include:
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When providers seek Medicare payment they do not deserve but have not knowingly or intentionally done so, this is known as:
When providers seek Medicare payment they do not deserve but have not knowingly or intentionally done so, this is known as:
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When a person or company knowingly deceives Medicare as an intentional act to receive inappropriate payment from the program, this is known as:
When a person or company knowingly deceives Medicare as an intentional act to receive inappropriate payment from the program, this is known as:
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With intent refers to:
With intent refers to:
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Without intent refers to:
Without intent refers to:
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Billing for services, supplies, or equipment that were not medically necessary or not provided is known as:
Billing for services, supplies, or equipment that were not medically necessary or not provided is known as:
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Which of the following is not considered a true statement regarding the history of claims?
Which of the following is not considered a true statement regarding the history of claims?
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Which of the following is not a common claim error?
Which of the following is not a common claim error?
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- A private or public company that often serves as the middleman between providers and billing groups, payers, and other health care partners for the transmission and translation of electronic claims information into the specific format required by payers is known as:
- A private or public company that often serves as the middleman between providers and billing groups, payers, and other health care partners for the transmission and translation of electronic claims information into the specific format required by payers is known as:
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Have a 'claim scrubber' program that will scrub the claim before it is sent to payers.
Have a 'claim scrubber' program that will scrub the claim before it is sent to payers.
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- A time-consuming process that frequently causes payment delays.
- A time-consuming process that frequently causes payment delays.
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- Payers typically do not inform providers of the status of their claims.
- Payers typically do not inform providers of the status of their claims.
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- Requires office collection staff to perform the extra task of making phone calls to key payers to determine whether claims are being processed.
- Requires office collection staff to perform the extra task of making phone calls to key payers to determine whether claims are being processed.
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- Payment is quicker, claims usually received by a payer within 24 hours.
- Payment is quicker, claims usually received by a payer within 24 hours.
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- Office cost is reduced by eliminating the need for stamps, forms, and excess office staff labor.
- Office cost is reduced by eliminating the need for stamps, forms, and excess office staff labor.
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- Claims can be entered from anywhere with Internet access with real-time response.
- Claims can be entered from anywhere with Internet access with real-time response.
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- Results can be viewed easily on a computer screen and information printed as needed.
- Results can be viewed easily on a computer screen and information printed as needed.
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Which of the following is not one of the necessary pieces of information to have before calling to follow up on a claim?
Which of the following is not one of the necessary pieces of information to have before calling to follow up on a claim?
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The process of billing a secondary insurance company involves which of the following?
The process of billing a secondary insurance company involves which of the following?
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- A group insurance that entitles members to services provided by participating hospitals, clinics, and providers.
- A group insurance that entitles members to services provided by participating hospitals, clinics, and providers.
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- All of the providers in the network are required to file a claim to get paid.
- All of the providers in the network are required to file a claim to get paid.
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Patients do not have to file a claim, and the provider may not charge a patient directly or send a bill.
Patients do not have to file a claim, and the provider may not charge a patient directly or send a bill.
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- A type of insurance in which contracted services are provided by providers who maintain their own offices.
- A type of insurance in which contracted services are provided by providers who maintain their own offices.
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- A network of providers and hospitals that are joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers and their families for a discounted fee.
- A network of providers and hospitals that are joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers and their families for a discounted fee.
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If a patient receives health care from a network provider, he or she would usually not need to file a claim.
If a patient receives health care from a network provider, he or she would usually not need to file a claim.
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If the patient receives out-of-network services, he may have to pay the provider in full and then file a claim with the insurance to get reimbursed.
If the patient receives out-of-network services, he may have to pay the provider in full and then file a claim with the insurance to get reimbursed.
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- Patients are responsible for any part of the provider's fee that the insurance does not pay.
- Patients are responsible for any part of the provider's fee that the insurance does not pay.
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- ________________ means that the doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.
- ________________ means that the doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services.
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Ambulatory payment classifications (APCs) are:
Ambulatory payment classifications (APCs) are:
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When claim form errors are identified by the third-party payers, the claim is then rejected. Which of the following is not considered an error?
When claim form errors are identified by the third-party payers, the claim is then rejected. Which of the following is not considered an error?
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When a patient's health insurance plan supports the ability to check electronically the amount of copayment a patient will be responsible for and the amount of payment the insurance company will make; this is known as:
When a patient's health insurance plan supports the ability to check electronically the amount of copayment a patient will be responsible for and the amount of payment the insurance company will make; this is known as:
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Information required to post on the patient account includes all of the following except:
Information required to post on the patient account includes all of the following except:
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The primary insurance information will be placed in _______ of the CMS-1500 form for secondary billing.
The primary insurance information will be placed in _______ of the CMS-1500 form for secondary billing.
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Study Notes
Third-Party Reimbursement
- Payment for services rendered by someone other than the patient; known as third-party reimbursement.
Electronic Claims Processing
- Since 2005, providers urged to submit claims electronically, enhancing efficiency.
- Electronic Data Interchange (EDI) transactions streamline submission and payment processes.
Claim Forms
- CMS-1500 form, accepted by both Medicare and Medicaid for insurance claims.
- The UB-04 form is also referred to as the CMS-1450 form.
Claims Rejections and Adjustments
- Claims are rejected with a request to correct and resubmit if errors are found.
- An insurance adjustment can be posted without noting the secondary insurance company.
Claim Number and Service Dates
- A claim number uniquely identifies submissions made to insurance companies.
- Dates of service indicate the timeframe in which health-related services were provided.
Insurance Payments and Patient Responsibilities
- Not allowed amount represents what the insurance company does not cover.
- Coinsurance co-payment refers to a patient's share of the bill.
- Patients may owe amounts for services billed by the provider.
Insurance Identification
- Insured ID number should match the patient’s insurance card.
Assignment of Benefits
- An assignment of benefits clause directs payment from the third-party payer to the provider.
Claims Tracking Systems
- Manual claims tracking often causes delays and requires additional follow-up efforts.
- Electronic Claims Tracking (ECT) systems provide immediate access to claim statuses.
Claims Filing Requirements
- The steps for filing a third-party claim include verifying insurance details and the patient's information.
- Essential information excludes co-pay receipts when filing third-party claims.
Fraud and Abuse
- Abuse involves seeking undeserved Medicare payments without knowledge of wrongdoing.
- Fraud is the intentional deception to gain payment from Medicare.
Clearinghouses
- Third-party companies facilitate the transmission and translation of electronic claims, acting as intermediaries.
HMO and PPO Insurance Types
- Health Maintenance Organization (HMO) mandates providers to file claims without direct billing to patients.
- Preferred Provider Organization (PPO) offers flexibility but may require out-of-pocket payments for out-of-network services.
Real-Time Adjudication
- A feature allowing patients to check copayment responsibilities and insurance payments instantly.
Claim Submission Guidelines
- The Administrative Simplification Compliance Act (ASCA) dictates specific requirements for submitting paper claims.
- For secondary billing on the CMS-1500 form, primary insurance information is entered in Block 9.
Insurance Claim History
- Common claim errors do not include the correct place of service code.
Claiming for Secondary Insurance
- To bill secondary insurance, a new bill must be created after the primary insurance payment is received.
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Description
Explore the intricacies of the healthcare claims process, including third-party reimbursements, electronic claims processing, and common claim forms. This quiz covers essential concepts like claims rejections, adjustments, and patient responsibilities, enhancing your understanding of health insurance mechanics.
