Deck 26: Billing and Reimbursement

Question 1

The date in block 14 is the date

A) of the filing of the claim.
B) of the onset of the illness.
C) the patient signed the claim.
D) the provider signed the claim.

Answer 1

of the onset of the illness.

Question 2

The physician's office place-of-service code is

A) 9.
B) 10.
C) 11.
D) 12.

Answer 2

11.

Question 3

Which of the following steps to medical billing should be performed prior to rendering medical services?

A) Verify the patient's eligibility for insurance coverage.
B) Collect patient insurance information.
C) Code the diagnosis and procedures.
D) Complete the CMS-1500 health insurance claim form.
E) Both A and B

Answer 3

Both A and B

Question 4

Electronic data interchange is

A) transferring data back and forth between two or more entities.
B) sending information to one insurance carrier.
C) sending information to one clearinghouse for processing.
D) None of the above

Question 5

The physician's signature is located in block

A) 12.
B) 13.
C) 31.
D) 33.

Question 6

Which of the following is a common reason why insurance claims are rejected?

A) When a procedure listed is not an insurance benefit
B) Lack of insurance coverage on date of service
C) Not obtaining preauthorization for the service
D) Claim was sent to the wrong insurance plan

Question 7

Procedures performed on the patient are found in what block?

A) 24a
B) 24b
C) 24d
D) 24e

Question 8

The insured's name is found in block

A) 1.
B) 2.
C) 3.
D) 4.

Question 9

When completing the CMS-1500 form, which section contains information about the patient and the insured?

A) Section 1
B) Section 2
C) Section 3
D) Section 4

Question 10

To examine claims for accuracy and completeness before they are submitted is to _________ the claims.

A) correct
B) audit
C) revise
D) reject

Question 11

How many diagnoses can be reported on the CMS-1500?

A) Four
B) Eight
C) Twelve
D) Sixteen

Question 12

The patient's name is found in block

A) 1.
B) 2.
C) 3.
D) 4.

Question 13

A secondary health plan is noted in which block?

A) 11a
B) 11b
C) 11c
D) 11d

Question 14

The assignment of benefits is located in block

A) 12.
B) 13.
C) 27.
D) 33.

Question 15

The Federal Tax ID number (Box 25) for the provider filing the claim can be presented as

A) Social Security Number (SSN).
B) Employer Identification Number (EIN).
C) National Provider Identification (NPI).
D) Both A and B
E) All of the above

Question 16

Block 1 of the CMS-1500 contains what information?

A) Patient's name
B) Insured's name
C) Type of insurance coverage
D) Carrier address

Question 17

Claims that have errors or omissions that must be corrected and resubmitted to receive reimbursement are called _____________ claims.

A) clean
B) dirty
C) dingy
D) incomplete

Question 18

The insured's address in block 7 refers to the __________ address.

A) patient's
B) spouse's
C) policyholder's
D) insurance carrier's

Question 19

Which of the following is typically documented in the explanation of benefits (EOB)?

A) Patient's deductible
B) Co-insurance
C) Copayment
D) Both A and B
E) All of the above

Question 20

The billing provider's NPI number is placed in block

A) 31.
B) 32.
C) 33a.
D) 33b.

Question 21

The medical assistant should __________ the front and back of the patient's insurance card.

A) annotate
B) highlight
C) copy
D) None of the above

Question 22

The process of determining if a procedure or service is covered by the insurance plan and what the reimbursement is for that procedure is the definition of

A) eligibility.
B) precertification.
C) medical necessity.
D) capitation.

Question 23

A claim that is missing information and is returned to the provider for correction and resubmission is called a(n) __________ claim.

A) clean
B) dirty
C) dingy
D) incomplete

Question 24

Abuse is knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program. Fraud is an unintended action that results in an overpayment to the healthcare provider.

A) Both statements are true.
B) Both statements are false.
C) The first statement is true and the second statement is false.
D) The first statement is false and the second statement is true.

Question 25

Patient care approached from a holistic approach defines

A) Health Maintenance Organizations.
B) Patient-Centered Medical Home.
C) precertification.
D) medical necessity.

Question 26

If the ICD-10-CM codes and the CPT/HCPCS codes do not match the claim will not show __________.

A) eligibility
B) precertification
C) medical necessity
D) capitation

Question 27

The provider is paid a set amount for each enrolled person assigned to them, per period of time, whether or not that person has received services is the definition of

A) eligibility.
B) precertification.
C) medical necessity.
D) capitation.

Question 28

Meeting the stipulated requirements to participate in the healthcare plan is the definition of

A) eligibility.
B) precertification.
C) medical necessity.
D) capitation.

Question 29

To settle or determine judicially is the definition of

A) copayment.
B) deductible.
C) co-insurance.
D) adjudicate.

Question 30

Patients belonging to a MCO usually are required to get a referral from their ____ before seeing a specialist.

A) HMO
B) EPO
C) PCP
D) CMS

Question 31

Which of the following is a fixed amount per visit and is typically paid at the time of medical services?

A) Copayment
B) Deductible
C) Co-insurance
D) Both A and B

Question 32

Which of the following methods can be used to determine a patient's eligibility for insurance?

A) Calling the provider services number on the back of the health insurance ID
B) Using the provider web portal sponsored by the patient's health insurance company
C) Both A and B
D) None of the above

Question 33

Which of the following steps is needed to obtain precertification?

A) Call provider services phone number on the back of the patient's health insurance ID card.
B) Provide the insurance company with procedures/services requested and the diagnoses.
C) Document the outcome of the call in the patient's health record.
D) All of the above

Question 34

A(n) __________ claim has been completed accurately and completely.

A) clean
B) dirty
C) dingy
D) incomplete

Question 35

The patient billing record includes which of the following information?

A) Insurance billing information
B) Diagnostic information
C) Procedural information
D) Medication information

Question 36

The first step in filing a claim with a third-party is

A) verify all charges and fees.
B) proof read the claim information.
C) complete the precertification process.
D) obtain accurate billing information from the patient.

Question 37

Patients sign an __________ of benefits form so that the physician will receive payment for services directly.

A) precertification
B) eligibility
C) assignment
D) adjudication

Question 38

Services and/or supplies used to treat the patient's diagnosis meet the accepted standard of medical practice is the definition of

A) eligibility.
B) precertification.
C) medical necessity.
D) capitation.

Question 39

Claims submitted to a(n) __________ are forwarded to individual insurance carriers.

A) scrubber
B) direct biller
C) clearinghouse
D) None of the above

Question 40

The medical assistant should always follow office __________ for claim review and signatures.

A) rules
B) policies
C) conventions
D) directions

Question 41

The National Provider Identifier is assigned by the AMA.

Question 42

After the deductible has been met the policyholder is responsible for a certain percentage of the bill is the definition of

A) copayment.
B) deductible.
C) co-insurance.
D) adjudicate.

Question 43

A PAR provider can bill the patient for the difference between their fee and insurance companies allowed amount.

Question 44

When the birthday rule is used to determine which policy is primary and which is secondary, it is the policy of the person who is the oldest that is considered primary.

Question 45

Electronic claims are submitted via the internet.

Question 46

A set dollar amount that the patient must pay for each office visit is the definition of

A) copayment.
B) deductible.
C) co-insurance.
D) adjudicate.

Question 47

Insurance information should be collected on the first visit.

Question 48

Claims that are done by direct billing first go to a clearinghouse.

Question 49

Dirty claims cannot be resubmitted.

Question 50

A set dollar amount that the policyholder must pay before the insurance company starts to pay for services is the definition of

A) copayment.
B) deductible.
C) co-insurance.
D) adjudicate.