Healthcare Claims and Reimbursement Process

Questions and Answers

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:

Send claims electronically

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:

Rejected with a request to resubmit the form with corrections Signup and view all the answers

How many digits are in a National Provider Identifier (NPI) number?

10 Signup and view all the answers

What is the first step in completing a claim form?

Check for a photocopy of the patient's insurance card Signup and view all the answers

Electronically processing claim forms to insurance carriers:

Reduces the amount of preparation time for the claims processor Signup and view all the answers

Which form is also known as the UB-04 form?

CMS-1450 Signup and view all the answers

Which of the following is not a fee usually charged by a clearinghouse?

Customer service fee Signup and view all the answers

Which of the following is not an advantage of using an Electronic Claims Tracking (ECT) system?

All claims are guaranteed to be paid if the forms are filled out correctly. Signup and view all the answers

Manual claims tracking:

Frequently causes payment delays Signup and view all the answers

When following up on a delinquent claim, if the carrier tells you that it is still in process, you should:

Request an anticipated date of payment Signup and view all the answers

When applying an insurance adjustment to a patient's account, you are not typically required to post the:

Name of the secondary insurance company that might be billed later Signup and view all the answers

Number that identifies or refers to the claim that either the patient or the health provider submitted to the insurance company.

Claim number Signup and view all the answers

Beginning and end dates of the health-related service a patient received from a provider.

Date of service Signup and view all the answers

Amount of money that a patient's insurance company did not pay the provider.

Not allowed amount Signup and view all the answers

Amount of money a patient owes as a share of the bill.

Coinsurance co-payment Signup and view all the answers

Amount a provider billed the patient's insurance company for a service.

Charge Signup and view all the answers

Number assigned to a patient by the insurance company, which should match the number on the patient's insurance card.

Insured id number Signup and view all the answers

Code and brief description of the health-related service a patient received from a provider.

Type of service Signup and view all the answers

Name of the person who received the service.

Patient Signup and view all the answers

Authorizes benefits to be paid directly from a third-party payer to a provider.

Assignment of benefits clause Signup and view all the answers

Standard claim form used for billing in medical offices.

CMS-1500 Signup and view all the answers

Book in which a list of insurance claims is kept.

Manual insurance log Signup and view all the answers

Type of payment used for centuries in the past.

Bartered goods Signup and view all the answers

This must be completed before submitting electronic media claims to Medicare.

Standard Electronic Data Interchange (EDI) Enrollment form Signup and view all the answers

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.

Secondary insurance Signup and view all the answers

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.

Signature on file Signup and view all the answers

Use of these allows a medical facility or provider's office to submit transactions faster and be paid sooner.

Electronic Data Interchange (EDI) transactions Signup and view all the answers

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).

Explanation of Benefits (EOB) form Signup and view all the answers

Developed to report the health care provided to the source of payment when third-party reimbursement was created.

Claim form Signup and view all the answers

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.

Clearinghouse Signup and view all the answers

This amount is posted from the insurance payment or insurance adjustment.

Credit column Signup and view all the answers

Paper claim form that may be submitted by an institutional provider that meets certain requirements.

CMS-1500 Signup and view all the answers

Sets forth the very specific requirements a provider must meet in order to submit paper claim forms and receive CMS payment.

Administrative Simplification Compliance Act (ASCA) Signup and view all the answers

The most common of these are federal and state agencies, insurance companies, and workers' compensation.

Third-party reimbursers Signup and view all the answers

Similar to the EOB but is the document provided by the payer to the provider.

Remittance Advice form Signup and view all the answers

These give you immediate access to the status of a claim or group of claims.

Electronic Claims Tracking (ECT) systems Signup and view all the answers

Information required to file a third-party claim on the CMS-1500 form includes all but:

The co-pay receipt given to patient at time of visit Signup and view all the answers

The steps to file a third-party claim and accurately complete the CMS-1500 form include:

Signup and view all the answers

When providers seek Medicare payment they do not deserve but have not knowingly or intentionally done so, this is known as:

Abuse Signup and view all the answers

When a person or company knowingly deceives Medicare as an intentional act to receive inappropriate payment from the program, this is known as:

Fraud Signup and view all the answers

With intent refers to:

Abuse Signup and view all the answers

Without intent refers to:

Fraud Signup and view all the answers

Billing for services, supplies, or equipment that were not medically necessary or not provided is known as:

Fraud Signup and view all the answers

Which of the following is not considered a true statement regarding the history of claims?

Signup and view all the answers

Which of the following is not a common claim error?

Signup and view all the answers

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:

Clearinghouse Signup and view all the answers

Have a 'claim scrubber' program that will scrub the claim before it is sent to payers.

Electronic Signup and view all the answers

A time-consuming process that frequently causes payment delays.

Manual Signup and view all the answers

Payers typically do not inform providers of the status of their claims.

Manual Signup and view all the answers

Requires office collection staff to perform the extra task of making phone calls to key payers to determine whether claims are being processed.

Manual Signup and view all the answers

Payment is quicker, claims usually received by a payer within 24 hours.

Electronic Signup and view all the answers

Office cost is reduced by eliminating the need for stamps, forms, and excess office staff labor.

Electronic Signup and view all the answers

Claims can be entered from anywhere with Internet access with real-time response.

Electronic Signup and view all the answers

Results can be viewed easily on a computer screen and information printed as needed.

Electronic Signup and view all the answers

Which of the following is not one of the necessary pieces of information to have before calling to follow up on a claim?

The amount of copay received from the patient Signup and view all the answers

The process of billing a secondary insurance company involves which of the following?

After payment is received from the primary insurance, you must create a new bill with the secondary insurance information, or perform the electronic task of submitting the claim to the secondary insurer. Signup and view all the answers

A group insurance that entitles members to services provided by participating hospitals, clinics, and providers.

HMO Signup and view all the answers

All of the providers in the network are required to file a claim to get paid.

HMO Signup and view all the answers

Patients do not have to file a claim, and the provider may not charge a patient directly or send a bill.

HMO Signup and view all the answers

A type of insurance in which contracted services are provided by providers who maintain their own offices.

IPA Signup and view all the answers

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.

PPO Signup and view all the answers

If a patient receives health care from a network provider, he or she would usually not need to file a claim.

PPO Signup and view all the answers

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.

PPO Signup and view all the answers

Patients are responsible for any part of the provider's fee that the insurance does not pay.

PPO Signup and view all the answers

________________ 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.

Assignment Signup and view all the answers

Ambulatory payment classifications (APCs) are:

All of the above Signup and view all the answers

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?

The correct place of service code Signup and view all the answers

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:

Real time adjudication Signup and view all the answers

Information required to post on the patient account includes all of the following except:

The date the claim was submitted Signup and view all the answers

The primary insurance information will be placed in _______ of the CMS-1500 form for secondary billing.

Block 9 Signup and view all the answers

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.