FINALS for Medical Billing & Coding | Baamboozle - Baamboozle

Medicare claims are sometimes outsourced to private affiliates or Medicare Administrative Contractors (MAC) to be processed

True

The original Medicare plan includes both Part A & B and is also called "Medicare Fee-For-Service

True

The "Tricare for Life" plan is a substitution to Medicare benefit for Military Retirees, it is also primary to medicare

False

Medicare "spell of illness" is also known as "benefit period"

True

With Tricare the uniformed service personnel who are either active duty. retired or died in active duty are known as

sponsors

Terminally ill Medicare beneficiaries receive end of life benefit through Respite Care

False

Medicare is a Federal program, Medicaid is administered by each state, and CMS monitors both program

True

To qualify for Medicare Part C a beneficiary needs to only have Medicare Part A coverage

False

A Primary Care Manager (PCM), is a Tricare Certified Physician assigned to a sponsor and is part of the Tricare provider network

True

When Medicaid is secondary to Medicare, Medicaid is referred to as a MEDIGAP plan

False

If someone qualifies for the Medicaid plan in one state, you will also automatically qualify for Medicaid in another state

False

Both active duty military personnel and veterans with disability can be enrolled in CHAMPVA upon retirement from the armed forces

False

A voided claim is one that upon presentation should not have been paid by Medicaid

True

Medicaid is the only benefit program, or payer that allows Retroactive coverage. It may go as far back as 90 days prior to the effective date of coverage

True

Tricare Select is a combination of Tricare Prime & Extra

False

Medicaid is jointly funded by the __________ and ________ government to assist states in providing adequate medical care to qualified individuals

federal, state

Medicare Part C is called

Medicare Advantage

Eligibility and benefit for Medicaid can be amended by state legislature

anytime during the year, at times more than once

Lead agents of specific Military treatment Facilities hold the position of

Commander

With the RVUs Physician payment method, Medicare considers resources used in providing a service such as

physician specialty, practice expense (overhead), and malpractice expense

What type of services are exempt from copayments from Medicaid recipients?

Emergency, and Family Planning

Which is not a Tricare region?

North

The Medicare and Medicaid program were enacted in which year?

1965

The Medicare program is funded by this agency

Social Security Administration

Tricare Standard was previously known as

CHAMPUS

What is California's equivalent to the Medicaid program?

Medi-Cal

The maximum fee a Medicare non-par provider may charge for a covered service is called _______and the percentage is______

limiting charge/15%

MTF is the acronym for

Military Treatment Facilities

As a result of Legislation passed by some states ___________ is forbidden

Balance billing

Hospital Emergency room services are covered under which part of the Medicare program?

Part B

The Tricare Manage care Option/Plan that is similar to an HMO is

Tricare Prime

A medicare patient's signature on an Advance Beneficiary Notice must be obtained

prior to the beneficiary receiving any and only medical services that are not covered by Medicare

Medicaid is always the

payer of the last resort

The steps in the revenue cycle in the numerical order of occurrence from 1st to last

1) Clearinghouse transmits claims data to payers, 2) Payer performs claims validation, 3) Payer approves claim for payment, 4) Payer generates remittance advice

Review for medical necessity of inpatient care prior to admission

pre-admission review

Provides comprehensive healthcare services to voluntarily enrolled members on a prepaid basis

HMO

Grants prior approval for reimbursement of a healthcare service

preauthorization

Organization of affiliated provider's sites that offer joint healthcare services to subscribers

IDS

Contracted network of healthcare providers that provide care to subscribers for a discounted fee

PPO

Provides benefits to subscribers who are required to receive services from network providers

EPO

Review for medical necessity of tests/procedures ordered during inpatient hospitalization

concurrent review

Arranging appropriate healthcare services for discharged patients

discharge planning

Patients are free to use the managed care panel of providers or self-refer to non-managed care providers

POS

What is the name of the federal law that protects consumers against harassing phone calls from collectors

Fair Debt Collection Practice Act

The "birthday law" states that the "child" whose birth year cccurs first on the calendar is the primary insured of coverage

False

Accreditation is a required (not voluntary) process that healthcare facility must undergo

False

The claim adjudication process occurs at the provider's office during transmission

False

A second opinion is required by managed care plans before an elective surgery is scheduled. This leads to a decrease in surgical procedures

True

According to __________ rule if a physician provides services that cost less than the managed care agreement the physician will make a profit

Capitation Plan

The life cycle of an insurance claim begins or is initiated

when the appointment is made, or when the patient arrives at the office for registration

The individual responsible for paying the medical bills is called

Guarantor

Managed Care HMO plans are usually characterized by having features such as

referrals, and prepaid or capitation features

Procedure or service reported on a claim that is not included on the payer's benefit list are

non-covered benefits

A term used for requirements created by accreditation organization is

standards

A ____________ is responsible for supervising and coordinating healthcare services for enrollees

primary care provider

Which term best describes those covered by managed healthcare plan services?

enrollees

The intent of managed health care was to

provide affordable comprehensive, prepaid health care services

This provision ensures covered benefits will be paid by primary and secondary payers in the correct order?

coordination of benefits

A primary care provider is also called a

gatekeeper

Program includes activities that assess the quality of care provided in healthcare settings

Quality Assurance

A claim that has been denied because of an error or omission is considered a(n)

open claim

Which is considered a covered entity?

Gateway Clearinghouse who submits electronic claims

Dr. Erin Helper is in-network with Aetna insurance. She billed $150. in charges but only $90. was allowed. She cannot bill the patient for the balance because

she "accepts assignment"

__________Which facilitates processing of nonstandard claims data elements into standard data elements?

clearinghouse

___________ The transmission of claims data to payers or clearinghouses is called claims

submission

This document is sent to the patient by Medicare to show claim payment information

Medicare summary notice

Which authorizes the payer to reimburse the provider directly?

assignment of benefits

Established quality standards for all laboratory testing to ensure the accuracy & reliability

CLIA

The ability to be friendly, helpful and positive while performing one's job duties

attitude

Global concept that includes the collection of patient information documented by a number of providers

EHR (Electronic Health Record)

Conduct or qualities that characterize a professional person, how to behave at work

professionalism

This is an administrative within the department of health and human services

CMS

Latin for " let the master answer" legal doctrine holding that the employer is liable

respondeat superior

Report from insurance or commercial payer that details the payment processing of a claim

Explanation of Benefits (EOB)

Healthcare coverage subsidized by employers and other organizations

group health insurance

An individual employed by the insurance to review health-related claims

claims examiner

Principle of right or good conduct

Ethics

CPT coding is Level I of the HCPCS system, and medical supply codes are Level II

True

Fluency in the language of medicine and the ability to use a medical dictionary as a reference are not necessary skills for a health insurance specialist

False

AHIMA is responsible for administering the Certified Coding Specialist Certification exam

True

The term Electronic Medical Record (EMR) applies to patient's medical record from a single practice, and EHR is more of a global concept

True

ICD-10-CM stands for International Classification of Diseases. It is used to report diagnosis and conditions

True

The primary intent of HIPAA is to provide better access to health insurance, limit fraud and abuse, and reduce administrative cost

True

A physician who is employed by a hospital and gets a pay check is an independent contractor

False

The coinsurance is a fixed amount of the cost-share paid by a Payer to a provider

False

The Explanation Of Benefit is sent to the patient by an insurance company provides claim information

True

Medical malpractice insurance covers physicians and other healthcare professionals for liability arising from negligence

True

The employer identification or Tax Id # is issued by

Internal Revenue Service

Dr. Jones ordered a neck x-ray because Kelly had knee pain. The procedure did not meet ___________ because the diagnosis did not justify the service

medical necessity

The problem-oriented record (POR) includes the following four components

database, problem list, initial plan and progress notes

"I am experiencing severe headache for 2 weeks," the SOAP format documents that statement in the _________ portion of the clinic note

subjective

Which is a primary purpose of the patient record?

ensure continuity of care

The American Medical Billing Association offers which certification exam?

CMRS

A specific amount paid by a patient at the time of service is known as

copay

A remittance advice from_________contains___________

medicare/payment information about a claim

A healthcare provider submit a ________ to the payer requesting payment of health services

health insurance claim

This Government Health Benefit plan provides healthcare coverage to Americans seniors over the age of 65

Medicare

The first Blue Cross policy was introduced by

Baylor University in Dallas Texas

Healthcare coverage offered by ______ is called Group health Insurance

employers

The CPT coding system is published by ______ and the National codes are known as _____ created by CMS

AMA/HCPCS level II Codes

This Clause is implemented if an In-Network provider failed to meet the requirements associated with preauthorization approval for a claim

a Hold harmless

A healthcare practitioner is also called a

provider