Which report is sent to the patient by the payer/insurance to clarify the results of claims processing?
(EOB) explanation of benefits
If a veteran is rated as 100 percent permanently and totally disabled as a result of a service connected condition, which program will provide benefits to the veteran's dependents?
(CHAMPVA) Civilian Health and Medical Program of the Department of Veterans Affairs
The first Blue Cross policy was introduced by
Baylor University in Dallas, Texas
When a patient states, "I haven't been able to sleep for weeks," the provider who uses the SOAP format documents that statement in the_________portion of the clinic note.
subjective
The Health Care and Education Reconciliation Act (HCERA) amended PACA t implement health care reform initiatives, which______tax credits for individuals so they could purchase health care insurance.
increased
The primary purpose of the record is to provide for_______, which involves documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment
continuity of care
The percentage of costs a patient shares with the health plan (e.g., plan pays 80 percent of costs and patient pays 20 percent) is called
coinsurance
the American Medical Billing Association offers which certification exam?
(CMRS) Certified Medical Reimbursement Specialist
Which clause is implemented if the requirements associated with prior approval of a claim prior to payment are not met?
hold harmless
Which is the focus of promoting intraoperability (pi) programs
improving patient access to health information and reducing the time and cost required of providers to comply with the programs requirements
Physicians and other health care professionals purchase_____insurance to protect them from liability relating to claims arising from patient treatment
medical malpractice
Evidence of the first health insurance policy to provide private health care coverage for injuries that did not result in death appeared in which year?
1850
In 2000, which type of health plan was introduced as a way to encourage individuals to locate the best health care at the lowest price possible, with the goal of holding down health care costs?
consumer-driven
The terms electronic health record (ehr) and electronic medical record (emr) are often used interchangeably, but the ____is a more global concept that includes the collection of patient information documented by a number of providers at
electronic health record
Which organization is responsible for administering the Certified Coding Specialist certification exam?
(AHIMA) American Health Information Management Association
The intent of HIPAA legislation is to
create better access to health insurance, limit fraud and abuse, and reduce administrative costs.
The document submitted to the payer requesting reimbursement is called a(n)
Health insurance claim
The Patient Protection and Affordable Care Act (PPACA) was signed into federal law by President Obama on March 23, 2010, and resulted in creation of a(n)______
health insurance marketplace
By whom is the employer identification number (EIN) assigned?
Internal Revenue Service (IRS)
A Remittance Advice (RA) contains
payment information about a claim
Which was the first commercial insurance company in the United States to provide private health care coverage for injuries not resulting in death?
Franklin Health Assurance Company
What is CLIA?
It is an agency responsible for laboratory guidelines and procedural maintenance.
Which requires health insurance specialists to differentiate among technical descriptions of similar procedures in the CPT coding manual?
critical thinking
RA is sent to
the physician from medicare
Some health insurance companies require_________for treatment provided by specialists and documentation of post treatment reports.
prior approval
Which coding system was created in 1984?
HCPCS
Which has as its goal access to health coverage for every individual, regardless of the system implemented to achieve that goal?
universal health insurance
High blood pressure is an example of a
diagnosis
Employers are generally considered liable for the actions and omissions of employees as performed and committed within the scope of their employment. This is known as
respondeat superior
In a teaching hospital, general documentation guidelines allow______ to document physician services in the patient's medical record.
both residents and teaching physicians
ICD-10-CM codes are assigned to______on inpatient and outpatient claims
diagnosis
ICD-10-CM is for
Diagnosis/Conditions
Major medical insurance provides coverage for__________ILLNESSSES AND INJURIES, INCORPORATING LARGE DEDUCTIBLES AND LIFETIME MAXIMUM AMOUNTS.
catastrophic or prolonged
Health care coverage offered by___________is called group health insurance.
employers
The provider who uses the SOAP format documents the physical examination in the ______portion of the clinic note
objective
The CPT coding system is published by the
(AMA) American medical Association
Third party administrators (TPAs) administer health care plans and process claims, serving as a
system of checks and balances for labor and management
National codes are associated with
HCPCS level II
Which is a primary purpose of the patient record?
ensure continuity of care
HCPCS Level II/National codes is for
Supplies
The administrative agency responsible for establishing rules for Medicare claims processing is called the
Centers for Medicare and Medicaid Services (CMS)
Third-Party Payer______review CMS-1500 claims to determine whether the charges are reasonable for payment
claims examiner
The skilled nursing facility prospective payment system (SNFPPS) generates________payments for each skilled nursing facility admission
per-diem
Patients with health insurance may require_______for treatment by specialists and documentation of post treatment reports
prior approval
The concept that every procedure or service reported to a third-party payer must be linked to a condition that justifies that procedure or service is called medical
necessity
What is Ms/Drg?
It is a payment method used by medicare to reimburse inpatient hospital service Ms-Drg codes.
A new schedule for Medicare services was implemented as part of OBRA in 1989 and 1990, replacing the regional "usual and reasonable" payment basis with a fixed fee schedule called
(RBRVS) Resource-Based Relative Value Scale
The Clinical Laboratory improvement Act (CLIA) established quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results.
regardless of where the test was performed.
The National Correct Coding initiative (NCCI) promotes national correct coding methodologies and eliminates improper coding. NCCI edits are developed based on coding conventions defined in___.current standards of medical and surgical coding
CPT
Which type of insurance should be purchased by health insurance specialist independent contractors?
errors and omissions
The Hill-Burton Act provided federal grants for modernizing hospitals that had become obsolete because of a lack of capital investment during the Great Depression and World War II (1929 to 1945). In return for federal funds I
facilities were required to provide services free or at reduced rates to patients unable to pay for care.
Which coding system is used to report diagnoses and conditions on claims?
ICD-10-CM
The process of assigning diagnoses, procedures, and services using numeric and alphanumeric characters is called
coding
The Patient Protection and Affordable Care Act (PPCA) amended the time period for filing Medicare fee-for-service claims to ____calendar year(s)after the date of service as the maximum time period for submission of all Medicare FFS claims
One (Time filing limit for medicare)
What is the Hill-Burton Act?
It is funding given to hospitals and in turn they cannot turn away anyone whether they have insurance or not
EOB is sent to
the physicians and patients explaining of benefit
Which is another title for a health insurance specialist?
reimbursement specialist
The Centers for Medicare and Medicaid Services (CMS) is an administration within the
Department of Health and Human Services. (DHHS)
Which organization created ICD?
(WHO) World Health Organization
If a patient is seen by a provider who orders a chest x-ray, which diagnosis should be linked with the procedure to prove medical necessity?
shortness of breath
A health care practitioner is also called a health care
provider
The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) enacted the_______prospective payment system (PPS).
diagnosis related groups
The systematic method of documentation that consists of four components (database, problem list, initial plan, and progress notes) is called the
problem-oriented record
Which legislation provides civilian employees of the federal government with medical care, survivors' benefits, and compensation for lost wages?
Federal Employees Compensation Act
When an individual chooses to perform services for another under an express or implied agreement and is not subject to the other's control, the individual is defined as a(n)
Independent contractor
Which is the most appropriate response to a patient who calls the office and asks to speak with the physician?
Explain that the physician is unavailable, and ask if the patient would like to leave a message
Which type of insurance guarantees repayment for financial losses resulting from an employee's act or failure to act?
bonding
The principles of right or good conduct are known as
ethics
The notice sent by the insurance company to the provider, which contains payment information about a claim, is the
explanation of benefit (eob)
The patient receives a report detailing the results of processing a claim (e.g., payer reimburses provider $80 on a submitted charge of $100). The provider receives a notice sent by the insurance company, which contains payment information
(eob) explanation of benefits
CMS developed the National Correct Coding Initiative (NCCI) to
eliminate improper coding and promote national correct coding methodologies
Which protects business contents (e.g., buildings and equipment) against fire, theft, and other risks?
Property Insurance
The problem oriented record (POR) includes the following four components:
database, problem list, initial plan and progress notes
Current Procedural Terminology (CPT) was developed by which organization in 1966?
American Medical Association
The government health plan that provides health care services to Americans over the age of 65 is called
Medicare
Quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the tests are performed were established specifically by___legislation.
(CLIA) Clinical Laboratory Improvement Act
The Blue Shield concept grew out of the lumbar and mining camps of the -----------region at the turn of the century.
Pacific Northwest
If a health insurance plan's prior approval requirements are not met by providers
payment of the claim is denied
Total practice management software (TPMS) is used to generate the EMR, automating which of the following medical practice functions?
patient registration
The electronic health record (EHR) allows patient information to be created at different locations according to a unique patient identifier or identification number, which is called
record linkage
When answering the telephone at a provider's office, you must
say the name of your office clearly
CPT is for
Procedures/Service
The ability to motivate team members to complete a common organizational goal display is called
leadership
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