Grants prior approval for reimbursement of a healthcare service
preauthorization
AHIMA is responsible for administering the Certified Coding Specialist Certification exam
True
ICD-10-CM stands for International Classification of Diseases. It is used to report diagnosis and conditions
True
The original Medicare plan includes both Part A & B and is also called "Medicare Fee-For-Service
True
The problem-oriented record (POR) includes the following four components
database, problem list, initial plan and progress notes
A claim that has been denied because of an error or omission is considered a(n)
open claim
Medicaid is jointly funded by the __________ and ________ government to assist states in providing adequate medical care to qualified individuals
federal, state
What is the name of the federal law that protects consumers against harassing phone calls from collectors
Fair Debt Collection Practice Act
To qualify for Medicare Part C a beneficiary needs to only have Medicare Part A coverage
False
The individual responsible for paying the medical bills is called
Guarantor
CPT coding is Level I of the HCPCS system, and medical supply codes are Level II
True
Medicaid is always the
payer of the last resort
This provision ensures covered benefits will be paid by primary and secondary payers in the correct order?
coordination of benefits
A voided claim is one that upon presentation should not have been paid by Medicaid
True
Review for medical necessity of inpatient care prior to admission
pre-admission review
Which is not a Tricare region?
North
Conduct or qualities that characterize a professional person, how to behave at work
professionalism
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
As a result of Legislation passed by some states ___________ is forbidden
Balance billing
The first Blue Cross policy was introduced by
Baylor University in Dallas Texas
Which is a primary purpose of the patient record?
ensure continuity of care
Principle of right or good conduct
Ethics
This Government Health Benefit plan provides healthcare coverage to Americans seniors over the age of 65
Medicare
What is California's equivalent to the Medicaid program?
Medi-Cal
The primary intent of HIPAA is to provide better access to health insurance, limit fraud and abuse, and reduce administrative cost
True
__________Which facilitates processing of nonstandard claims data elements into standard data elements?
clearinghouse
The claim adjudication process occurs at the provider's office during transmission
False
Arranging appropriate healthcare services for discharged patients
discharge planning
MTF is the acronym for
Military Treatment Facilities
If someone qualifies for the Medicaid plan in one state, you will also automatically qualify for Medicaid in another state
False
Eligibility and benefit for Medicaid can be amended by state legislature
anytime during the year, at times more than once
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
Medicare claims are sometimes outsourced to private affiliates or Medicare Administrative Contractors (MAC) to be processed
True
Established quality standards for all laboratory testing to ensure the accuracy & reliability
CLIA
The employer identification or Tax Id # is issued by
Internal Revenue Service
This Clause is implemented if an In-Network provider failed to meet the requirements associated with preauthorization approval for a claim
a Hold harmless
The Medicare and Medicaid program were enacted in which year?
1965
The intent of managed health care was to
provide affordable comprehensive, prepaid health care services
Medical malpractice insurance covers physicians and other healthcare professionals for liability arising from negligence
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
Terminally ill Medicare beneficiaries receive end of life benefit through Respite Care
False
A primary care provider is also called a
gatekeeper
Report from insurance or commercial payer that details the payment processing of a claim
Explanation of Benefits (EOB)
Organization of affiliated provider's sites that offer joint healthcare services to subscribers
IDS
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"
Global concept that includes the collection of patient information documented by a number of providers
EHR (Electronic Health Record)
A physician who is employed by a hospital and gets a pay check is an independent contractor
False
Accreditation is a required (not voluntary) process that healthcare facility must undergo
False
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
Which is considered a covered entity?
Gateway Clearinghouse who submits electronic claims
The "birthday law" states that the "child" whose birth year cccurs first on the calendar is the primary insured of coverage
False
This is an administrative within the department of health and human services
CMS
Procedure or service reported on a claim that is not included on the payer's benefit list are
non-covered benefits
Medicare "spell of illness" is also known as "benefit period"
True
"I am experiencing severe headache for 2 weeks," the SOAP format documents that statement in the _________ portion of the clinic note
subjective
A remittance advice from_________contains___________
medicare/payment information about a claim
Which authorizes the payer to reimburse the provider directly?
assignment of benefits
Medicare is a Federal program, Medicaid is administered by each state, and CMS monitors both program
True
With Tricare the uniformed service personnel who are either active duty. retired or died in active duty are known as
sponsors
The Tricare Manage care Option/Plan that is similar to an HMO is
Tricare Prime
Hospital Emergency room services are covered under which part of the Medicare program?
Part B
Which term best describes those covered by managed healthcare plan services?
enrollees
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
The Medicare program is funded by this agency
Social Security Administration
Healthcare coverage offered by ______ is called Group health Insurance
employers
Provides comprehensive healthcare services to voluntarily enrolled members on a prepaid basis
HMO
___________ The transmission of claims data to payers or clearinghouses is called claims
submission
A second opinion is required by managed care plans before an elective surgery is scheduled. This leads to a decrease in surgical procedures
True
A Primary Care Manager (PCM), is a Tricare Certified Physician assigned to a sponsor and is part of the Tricare provider network
True
This document is sent to the patient by Medicare to show claim payment information
Medicare summary notice
What type of services are exempt from copayments from Medicaid recipients?
Emergency, and Family Planning
A healthcare provider submit a ________ to the payer requesting payment of health services
health insurance claim
The coinsurance is a fixed amount of the cost-share paid by a Payer to a provider
False
A specific amount paid by a patient at the time of service is known as
copay
Program includes activities that assess the quality of care provided in healthcare settings
Quality Assurance
When Medicaid is secondary to Medicare, Medicaid is referred to as a MEDIGAP plan
False
Managed Care HMO plans are usually characterized by having features such as
referrals, and prepaid or capitation features
Review for medical necessity of tests/procedures ordered during inpatient hospitalization
concurrent review
A ____________ is responsible for supervising and coordinating healthcare services for enrollees
primary care provider
The ability to be friendly, helpful and positive while performing one's job duties
attitude
Contracted network of healthcare providers that provide care to subscribers for a discounted fee
PPO
Latin for " let the master answer" legal doctrine holding that the employer is liable
respondeat superior
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
With the RVUs Physician payment method, Medicare considers resources used in providing a service such as
physician specialty, practice expense (overhead), and malpractice expense
Provides benefits to subscribers who are required to receive services from network providers
EPO
Medicare Part C is called
Medicare Advantage
The maximum fee a Medicare non-par provider may charge for a covered service is called _______and the percentage is______
limiting charge/15%
Healthcare coverage subsidized by employers and other organizations
group health insurance
The American Medical Billing Association offers which certification exam?
CMRS
Tricare Standard was previously known as
CHAMPUS
Patients are free to use the managed care panel of providers or self-refer to non-managed care providers
POS
An individual employed by the insurance to review health-related claims
claims examiner
The "Tricare for Life" plan is a substitution to Medicare benefit for Military Retirees, it is also primary to medicare
False
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
Lead agents of specific Military treatment Facilities hold the position of
Commander
The CPT coding system is published by ______ and the National codes are known as _____ created by CMS
AMA/HCPCS level II Codes
A term used for requirements created by accreditation organization is
standards
Both active duty military personnel and veterans with disability can be enrolled in CHAMPVA upon retirement from the armed forces
False
Tricare Select is a combination of Tricare Prime & Extra
False
A healthcare practitioner is also called a
provider
The Explanation Of Benefit is sent to the patient by an insurance company provides claim information
True
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