Deck 15: Keys to Successful Claims Management

Question 1

Generally,if a claim is reduced or rejected,the problem lies with the:

A) provider's office.
B) patient.
C) insurance company.
D) fiscal intermediary.

Answer 1

provider's office.

Question 2

A common error that can cause a claim to be rejected is:

A) incorrect patient ID number.
B) missing physician's EIN number.
C) invalid CPT or ICD codes.
D) all of the above

Answer 2

all of the above

Question 3

Providers cannot waive Medicare copayments unless ____________ has been established and documented.

A) legitimate financial hardship
B) a secondary insurer
C) coordination of benefits
D) adjudication

Answer 3

legitimate financial hardship

Question 4

When a coordination of benefits situation exists,the health insurance professional should first:

A) disregard the primary payer.
B) disregard the secondary payer.
C) verify which payer is primary and which is secondary.
D) submit two claims simultaneously.

Question 5

An alternative to the suspension file is to record claims information on a columnar form called a/an:

A) explanation of benefits.
B) payment receiving form.
C) insurance claims register.
D) computerized claim form.

Question 6

The key to knowing how much of the claim was paid,how much was not,and why is the:

A) EOB.
B) EIN.
C) ROA.
D) PIN.

Question 7

Before the health insurance professional completes and submits health insurance claims,a __________ is typically on file.

A) signed and dated release of information
B) completed explanation of benefits form
C) coordination of benefits form
D) correct code initiative

Question 8

The basic responsibility of the National Correct Coding Initiative is to generate:

A) methods for correct coding.
B) documentation supporting edits.
C) correct code initiative edits.
D) initiate commercial claims edits.

Question 9

Adjudication is the process by which:

A) a claim is paid in a timely manner.
B) a claim is reviewed and payment decisions are made by the payer.
C) data are entered into an electronic file or account.
D) a healthcare provider is sued by a patient.

Question 10

Established patients should be required to update their information form:

A) daily.
B) monthly.
C) at least annually.
D) none of these; established patients do not need to update their information.

Question 11

If patients are covered by two insurance plans,the health insurance professional may have to submit a primary claim and a _____ claim.

A) principal
B) secondary
C) tertiary
D) none of these; patients cannot be covered under two different insurance plans

Question 12

A suspension file is a series of files customarily set up:

A) alphabetically.
B) numerically.
C) phonetically.
D) chronologically.

Question 13

A nine-digit number required by businesses to serve as their taxpayer identifying number is the:

A) Social Security Number (SSN).
B) National Provider Identifier (NPI).
C) Employer Identification Number (EIN).
D) Medical Practice Group Number (MGP).

Question 14

Services that usually require preauthorization or precertification include:

A) laboratory tests.
B) emergency room services.
C) routine "wellness" examinations.
D) inpatient hospitalization.

Question 15

Documenting the appropriate medical information in the patient's health record is the responsibility of the:

A) patient (if of legal age).
B) patient's parents or legal guardian.
C) insurance company.
D) healthcare provider.

Question 16

To complete the entire claims process,a paper claim normally takes:

A) 4 to 6 weeks.
B) 4 to 6 days.
C) 4 to 6 months.
D) up to 1 year.

Question 17

How frequently claims are submitted can vary depending on:

A) the size of the practice.
B) office staffing.
C) the type of claim.
D) all of the above

Question 18

An explanation of benefits is often referred to as a/an:

A) general ledger file.
B) remittance advice.
C) tracking file.
D) insurance claims register.

Question 19

What is the first key to successful claims processing?

A) Obtaining necessary preauthorization
B) Collecting and verifying patient information
C) Following payer guidelines
D) Proofreading to avoid errors

Question 20

The health insurance professional should be familiar with the CMS-1500 paper claim process because:

A) the NUCC recommends it.
B) it is a HIPAA mandate.
C) not all providers submit claims electronically.
D) the CMS-1500 form must be used for Medicare claims.

Question 21

Ideally,patients should be asked to update their information forms at least annually.

Question 22

An explanation of benefits (EOB)is sometimes called a remittance advice (RA).

Question 23

A suspension file is a series of files set up alphabetically and labeled according to the number of days since the claim was submitted.

Question 24

After the patient information form is completed,the health insurance professional should check it over to ensure the information is complete and legible.

Question 25

If there is a second insurance policy,it is important to check "yes" in Block ____________ on the CMS-1500 form and complete Blocks 9,9a,and 9d.

A) 9a
B) 10c
C) 11d
D) 21

Question 26

The EIN is a nine-digit number that serves as a taxpayer's identifying number.

Question 27

When a patient signs an assignment of benefits,he or she is authorizing the insurance carrier to send payment directly to the healthcare provider.

Question 28

It is the patient's responsibility to document nonmedical comments in his or her own health record.

Question 29

The book outlines 12 keys to successful claims processing.

Question 30

The Medicare program has a multileveled appeal process.How many levels are there?

A) three
B) four
C) five
D) six

Question 31

When initiating an appeal,in order that the appropriate steps are followed,the health insurance professional should consult the:

A) patient.
B) carrier's guidelines.
C) policy of the practice.
D) state law.

Question 32

If the health insurance professional believes a claim has been wrongly denied,he or she can:

A) file an appeal.
B) start a small claims lawsuit.
C) disregard the denied claim and resubmit it.
D) do nothing; once a claim is denied, it is finished.

Question 33

Appeals generally must be in writing and initiated within ___________ days.

A) 10 to 20
B) 30 to 60
C) 60 to 90
D) 360

Question 34

EOBs can be submitted only in electronic format.

Question 35

Participating providers can balance bill,but nonparticipating providers for commercial claims are not allowed to.

Question 36

The claims process actually starts with the patient's appointment.

Question 37

The type of Medicare coverage dictates the specific appeal filing process.

Question 38

Correct code initiative edits are the result of the National Correct Coding Initiative.

Question 39

When a claims error that could result in inaccurate reimbursement is discovered,a corrected claim should be prepared and submitted according to the payer's guidelines.

Question 40

If a patient is incapacitated in any way,the health insurance professional is not allowed (by law)to contact the patient's insurer to obtain preauthorization.

Question 41

If a health insurance professional discovers an error in a claim that could result,or already has resulted,in inaccurate reimbursement,what should be done?

Question 42

Real Time Claims Adjudication (RTCA)allows instant adjudication of an insurance claim.

Question 43

Only the provider has the right to appeal a rejected claim.

Question 44

Medicare secondary payer claims are claims that are submitted to another insurance company after they are submitted to Medicare.

Question 45

List the six keys to successful claims processing.

Question 46

Before appealing a claim,the health insurance professional should notify the insurer in writing that there has been an error.

Question 47

When it becomes necessary to include attachments with a paper claim,what provider information should appear on each document?

Question 48

Insurance companies usually have no time limits for filing appeals.

Question 49

If a patient and his or her spouse are covered under two separate employer group policies,it results in a coordination of benefits.

Question 50

What information can usually be deduced from an explanation of benefits (EOB)or remittance advice (RA)? Include at least five examples in your answer.

Question 51

There are five different levels of the Medicare appeals process.

Question 52

The National Correct Coding Initiative (NCCI)develops correct coding methods for CMS that are intended to reduce overpayments that result from improper coding.

Question 53

Not all medical practices follow the same strategy when it comes to the frequency of submitting insurance claims.What are some of the things that affect this process?

Question 54

Why should the health insurance professional photocopy both sides of a patient's health insurance identification card?

Question 55

Verifying a patient's healthcare coverage is an important duty of a health insurance professional.

Question 56

What are the basic rules for appealing a claim?

Question 57

While coordination of benefits (COB)does not occur as often as it once did,it is still an occasional occurrence.What two things should a health insurance professional do when this situation arises?

Question 58

HIPAA has developed a transaction that allows payers to request additional information to support claims.

Question 59

Explain how the Health Care Claim Status Inquiry/Response system works.

Question 60

List at least 4 ways for optimizing the billing and claims process.