Medical Billing & Coding | Baamboozle - Baamboozle

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The cycle of an insurance claim is initiated when the

health insurance specialist complete the CMS-1500 claim

A nonprofit organization that contracts with and acquires the clinical and business assets of physician practices is called a

medical foundation

(IDS) Integrated Delivery System is an

organization of affiliated providers' sites that offer joint health care services to subscribers

The primary care provider is responsible for

supervising and coordinating health care services for enrollees

The analysis of reimbursement received from third-party payers identifies variations in expected payments or contracted rates and may result in submission of ____________ to third-party payers

appeal letters

Electronic claims are

checked for accuracy by billing software programs or a health care clearinghouse

CMS-1500 or UB-04 claims that are resubmitted to third-party payers usually result in payment delays and claims denials. The resubmission of claims is a result of

entering late or lost charges or making corrections to previously processed CMS-1500 or UB-04 claims

Which requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions?

truth in Lending Act

Which is an example of supporting documentation?

operative report

Which CPT modifier will require supporting documentation for payment?

-22 (unusual procedural services)

Which describes any procedure or service reported on a claim that is not included on the payer's master benefit list?

noncovered benefit

A series of fixed-length records submitted to payers to bill for health care services is an electronic

flat file format

The sorting of claims upon submission to collect and verify information about the patient and provider is called claims

processing

Concurrent review

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

Currently, more than 70____ Americans are enrolled in some type of managed care program in response to regulatory initiatives affecting health care cost and quality

million

Which of the following steps would occur first?

Health insurance specialist completes electronic or paper based claim

(POS) Point-Of-Service Plan

patients can use the managed care panel of providers (paying discounted health care costs) or self-refer to out-of-network providers,and higher health care cost

If the claim was denied because the service is not covered by the payer, the claim is

not paid by the third-party payer

Which would likely be subject to a managed care plan quality review?

results of patient satisfaction surveys

Managed care organizations impact a practice's administrative procedures by requiring

special patient interviews to ensure preauthorization and to explain out-of-network requirements if the patient is self-referring

The term that describes requirements created by accreditation organizations is

standards

Which is a manual-based chronological summary of all transactions posted to individual patient accounts on a specific day?

daily accounts receivable journal

Which define employer contributions and ask employees to be more responsible for health care decisions and cost sharing?

consumer directed health plans

The chargemaster is a(n)

computer-generated list used by facilities, which contains procedures, services, supplies, revenue codes, and charges

Which term best describes those who receive managed health care plan services?

enrollees

A_________is responsible for supervising and coordinating health care services for enrollees

primary care provider

Patients can be billed for

noncovered procedures

Which administrative procedure should a medical practice follow when it contracts with a managed care organization (MCO)?

Maintain a separate bookkeeping systems for each capitated plan.

Comparing the claim to payer edits and the patient's health plan benefits is part of claims

adjudication

Which is the method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients?

utilization management

Which supporting documentation is associated with submission of an insurance claim?

claims attachment

Which was created to provide standards to assess managed care systems in terms of indicators such as membership, utilization of services, quality, and access?

HEDIS

If a physician provides services that cost less than the managed care capitation amount, the physician will

make a profit

Deductibles, copayments, and noncovered charges are considered

self-pay balances billed to the patient

The provision in group health insurance policies that specifies in what sequence coverage will be provided when more than one policy covers the claim is

coordination of benefits

Which is considered the financial source document?

superbill or encounter form

Accreditation is a _______process that a health care facility can undergo to show that standards are being met.

voluntary

A clearinghouse that coordinates with other entities to provide additional services during the processing of claims is a

value-added network

The Quality Improvement System for Managed Care (QISMC) was established by

Medicare

The intent of mandating the Health Insurance Portability and Accountability Act (HIPAA) national standards for electronic transaction was to

improve the efficiency and effectiveness of the health care system

Which is an interpretation of the birthday rule regarding two group health insurance policies when the parents of a child covered on both policies are married to each other and live in the same household?

the parent whose birth month and day occurs earlier in the calendar year is the primary policyholder

Which type of consumer-directed health plan carries the stipulation that any funds unused will be lost?

health care reimbursement account

Arranging for a patient's transfer to a rehabilitation facility is an example of

discharge planning

The intent of managed health care was to

replace fee-for-service plans with affordable, quality care to health care consumers.

Which is assessed by the National Committee for Quality Assurance?

managed care plans

Which is the financial record source document usually generated by a hospital?

chargemaster

Which is a characteristic of delinquent commercial claims awaiting payer reimbursement?

the delinquent claims are resolved directly with the payer

Preauthorization

grants prior approval for reimbursement of a health care service

Which means that the patient and/or insured has authorized the payer to reimburse the provider directly?

assignment of benefits

Which must accept whether a payer reimburses for procedures or services performed?

participating provider

Noncovered benefits are also called an

exclusion

What is an accept of assignment?

the provider accepts the fee schedule from the payer

Managed care originally focused on cost_______by restricting health care access through utilization management and availability of limited benefits.

reductions

A claim that is rejected because of an error or omission is considered a(n)

open claim

The process of posting electronic remittances based on third-party payer reimbursement involves

analyzing electronic reimbursement received from payers to identify variations in expected payments

Employees and dependents who join a managed care plan are called

enrollees

(HMO) Health Maintenance Organization

provides comprehensive health care services to voluntarily enrolled members on a prepaid basis

Providers who do not accept assignment of Medicare benefits do not receive information included on the ______________, which is sent to the patient

Medicare Summary Notice

In managed care, the primary care provided (PCP) typically receives a capitation payment and is responsible for managing all if an individual's health care; when the PCP arranges for the individual to receive care from a specialist), is

Sub-Capitation

Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider?

common data file

Charged for services procedures, patient personal payments, and third-party payments are entered in the computerized

patient account record

(EPO) Exclusive Provider Organization

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

Which of the following steps would occur first?

clearinghouse transmits claims data to payers

Another name for the patient account record is the patient

ledger

Which is the fixed amount patients pay each time they receive health care services?

copayment

To determine if a patient is receiving concurrent care for the same condition by more then one provider, the payer will check the claim against the

common data file

Which is a group health insurance policy provision that prevents multiple payers from reimbursing benefits covered by other policies?

coordination of benefits

To determine whether a claim is delinquent, review the status of all outstanding claims from each payer and payments due from patients by generating an accounts receivable_____ report.

aging

Which is a voluntary process that a health care facility or organization undergoes to demonstrate that it has met standards beyond those required by law?

accreditation

Which act of legislation provided states with the flexibility to establish HMOs for Medicare and Medicaid programs?

OBRA

(PPO) Preferred Provider Organization is a

contracted network of health care providers that provide care to subscribers for a discounted fee.

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

submission

Preadmission review

review for medical necessity of inpatient care prior

A chronological summary of all transactions posted to individual patient accounts on a specific day is recorded on a(n)

day sheet

Supporting documentation that is attached to the CMS-1500 is either copied from the patient's chart or developed (e.g., letter delineating unlisted service provided). The letter is referred to (in the CPT coding manual) as a(n)

special report

Which act of legislation permitted large employers to self-insure employee health care benefits?

ERISA

A case manager is responsible for

developing patient care plans for health services provided to enrollees

What special handling is required if a patient requests a copy of the remittance advice (remit) that contains information about multiple patients?

identifying information about all patients except the requesting patient is removed

The person in whose name the insurance policy is issued is the

policyholder

Which federal law protects consumers against harassing or threatening phone calls from collectors?

Fair Debt Collection Practices Act

Diagnosis and procedure codes that are entered incorrectly during billing and claims processing result in ___________ by the third-party payer

denied and rejected claims

Which type of health plan funds health care expenses by insurance coverage and allows the individual to select one of each type of provider to create a customized network?

customized sub-capitation plan

Accreditation organizations develop________ that are reviewed during a survey process that is conducted both offsite and onsite

standards

Which is the best way to prevent delinquent claims?

verify health plan identification information on all patients

The Medical Center received a $100,000 capitation payment in January to cover the health care costs of 150 managed care enrollees. By the following January, $80,000 had been expended to cover services provided. The remaining $20,000 is

retained by the Medical Center as profit.

Administrative services performed on behalf of a self-insured managed care company can be outsourced to a(n)

third party administrator (TPA)

Which is considered a covered entity?

private-sector payers that process electronic claims

Discharge planning

arranging appropriate health care services for discharged patients

Which claim status is assigned by the payer to allow the provider to correct errors or omissions on the claim and resubmit for payment consideration?

pending