Question 1

An appeal for reconsideration of a carrier's decision on a claim must be made:
A)online.
B)in writing.
C)by phone and in writing.
D)with the help of an attorney.

Accepted Answer

Appeals for reconsideration of a carrier's decision on a claim must be made in writing, as it provides a physical record of the appeal and ensures that all necessary information is included. While phone communication may be helpful in resolving minor issues, a written appeal is necessary. Seeking legal help may not be necessary unless the claim involves complex legal issues.

Question 2

If a carrier downcodes a claim and the provider maintains that the reported services were medically necessary, the medical office specialist should:
A)send a bill to the patient for the remaining balance.
B)write off the remaining balance.
C)file an appeal with the insurance carrier.
D)send a complaint to the state insurance commissioner.

Accepted Answer

Filing an appeal with the insurance carrier is the best option in this situation. The provider should gather any additional documentation or information that supports the medical necessity of the services and submit an appeal to the carrier for reconsideration. Sending a bill to the patient for the remaining balance or writing off the balance would not be appropriate if the services were medically necessary and were provided in accordance with accepted standards of care. Sending a complaint to the state insurance commissioner would be premature and not likely to result in a resolution without first exhausting the appeals process with the carrier.

Question 3

During the patient's care, all procedures and tests are documented on the:
A)encounter form.
B)explanation of benefits.
C)claim form.
D)registration form.

Accepted Answer

The encounter form is where all procedures and tests performed during the patient's care are documented. The explanation of benefits (EOB) is a document provided by insurance companies to explain how they processed a claim. The claim form is used to submit a request for payment to an insurance company. The registration form contains patient demographic and insurance information but does not document procedures or tests performed during care.

Question 4

The two main methods used by providers to determine their fees are:
A)capitation-based and resource-based fee structures.
B)profit-based and charge-based fee structures.
C)charge-based and resource-based fee structures.
D)resource-based and usual-and-customary fee structures.

Accepted Answer

Charge-based and resource-based fee structures are the two main methods used by providers to determine their fees. Charge-based fee structures involve setting prices for specific services or procedures based on the costs incurred by the provider. Resource-based fee structures, on the other hand, calculate fees based on the amount of resources, including labor, materials, and overhead, used to provide a service. Capitation-based and profit-based fee structures are less common, while the usual-and-customary fee structure is no longer widely used.

Question 5

The steps that result in an insurance carrier's decision to either pay or deny a claim are known as:
A)allocation.
B)adjudication.
C)determination.
D)justification.

Accepted Answer

Adjudication is the process of reviewing and evaluating a claim to determine if it meets the policy guidelines and should be paid or denied. The process involves reviewing the details of the claim, verifying information, investigating any suspicious activity or errors, and making a decision based on the policy's terms and conditions.

Question 6

After a claim is processed, an explanation of benefits (EOB) is sent to the:
A)provider only.
B)patient only.
C)provider and the patient.
D)carrier's headquarters.

Accepted Answer

An explanation of benefits (EOB) is sent to both the provider and the patient.

Question 7

No matter what amount a provider charges for a given service, each third-party payer will establish the amount they will pay based on what is considered:
A)medically appropriate.
B)usual and ordinary.
C)usual, customary, and reasonable.
D)average.

Accepted Answer

Third-party payers establish the amount they will pay based on what is considered usual, customary, and reasonable (UCR). UCR refers to the customary fee charged for a particular medical service in a certain area as well as the reasonable cost of that service. The medical appropriateness or average cost of a service does not necessarily determine the amount that the third-party payer will cover.

Question 8

Claims processing involves the verification of medical necessity for the reported procedures; this task is performed by:
A)medical office specialists.
B)medical directors.
C)medical review examiners.
D)automated claims processors.

Accepted Answer

Medical review examiners are responsible for verifying medical necessity for reported procedures during the claims processing process. Medical office specialists may assist with the claims processing process, but they do not have the authority to make medical necessity determinations. Medical directors may provide guidance on medical policy and procedures but may not be directly involved in the claims processing process. Automated claims processors may assist with administrative tasks, but medical review examiners are required to make medical necessity determinations.

Question 9

The state official who has regulatory control over insurance carriers and can assist with disputes is the:
A)state attorney general.
B)state economic development director.
C)senior state senator.
D)state insurance commissioner.

Accepted Answer

The answer of The state official who has regulatory control...

Question 10

Resource-based fee structures consider all of the following factors EXCEPT the:
A)provider's location.
B)work involved.
C)overhead (expense) involved.
D)malpractice risk.

Accepted Answer

Resource-based fee structures do not consider the provider's location as a factor in determining fees. Instead, they focus on the work involved, overhead expenses, and malpractice risk.

Question 11

When providers determine what fee to charge by considering what other providers charge for similar services, this method is:
A)charge based.
B)research based.
C)resource based.
D)comparison based.

Accepted Answer

Charge-based pricing involves setting prices based on what others are charging for similar services.

Question 12

If no payment is made on a claim by the carrier because the patient has NOT yet satisfied the deductible:
A)an EOB is sent to the patient only.
B)an EOB is sent to the provider only.
C)an EOB is sent to both the patient and the provider.
D)no EOB is sent.

Accepted Answer

The answer of If no payment is made on a...

Question 13

When treatment is determined to be appropriate for the diagnosis, the care is considered:
A)medically necessary.
B)medically appropriate.
C)medically reasonable.
D)medically feasible.

Accepted Answer

"Medically necessary" is the appropriate term to describe care that is determined to be appropriate for the diagnosis. This means that the care is essential to treat the patient's condition, and without it, the patient's health would be at risk. Medically appropriate or medically reasonable may also be used to describe care that is within the standard of care, but medically necessary specifically refers to care that is essential for the patient's well-being. Medically feasible refers to care that is physically possible to provide, but does not necessarily indicate whether it is appropriate or necessary for the patient's diagnosis.

Question 14

When a claim has been downcoded or denied by the insurance carrier, the medical office specialist can ask for reconsideration by filing:
A)an appeal.
B)an adjudication.
C)a complaint.
D)a request.

Accepted Answer

The answer of When a claim has been downcoded or...

Question 15

When third-party payers determine reimbursement, they consider UCR, which means:
A)usual, customary, and reasonable charges.
B)usual and common rates.
C)uniform, customary reimbursement.
D)usual and customary resources.

Accepted Answer

UCR stands for usual, customary, and reasonable charges, which refers to the fees that healthcare providers typically charge for a specific service or treatment in a geographic area. Third-party payers may use UCR to determine their reimbursement rates for these services, based on what is considered the usual or customary charge for that service in that area. The term "reasonable" is also included to ensure that the charges are not excessive or outside of the norm.

Question 16

The first step that the medical office specialist is responsible for before submitting a medical claim is:
A)verifying patient insurance benefits.
B)obtaining correct and complete patient information.
C)entering patient information data into the computer.
D)posting charges.

Accepted Answer

The answer of The first step that the medical office...

Question 17

If the reported services are deemed NOT medically necessary at the level reported, the claim will be:
A)denied.
B)downcoded.
C)upcoded.
D)pended.

Accepted Answer

The answer of If the reported services are deemed NOT...

Question 18

The notification sent by the insurance carrier to the patient and provider after a claim has been processed is known as a(n):
A)patient registration form.
B)encounter form.
C)charge slip.
D)explanation of benefits.

Accepted Answer

The notification sent by the insurance carrier to the patient and provider after a claim has been processed is known as an Explanation of Benefits (EOB). A patient registration form, encounter form, and charge slip are all documents used to gather information during the billing and reimbursement process, but they do not provide information about the status of a processed claim.

Question 19

If an insurance carrier does NOT reconsider a downcoded claim that has been appealed, the medical office specialist can:
A)request assistance from the state insurance commissioner.
B)file a complaint with the Department of Health and Human Services (DHHS).
C)file a complaint with the Centers for Medicare and Medicaid Services (CMS).
D)bill the patient for the remaining balance.

Accepted Answer

Requesting assistance from the state insurance commissioner is a viable option when an insurance carrier does not reconsider a downcoded claim that has been appealed. The state insurance commissioner oversees insurance operations and can intervene in disputes between insurance carriers and policyholders or medical providers.

Question 20

A claim that is removed from a payer's automated processing system for additional review is subject to:
A)preauthorization.
B)manual review.
C)medical-necessity examination.
D)claims edit.

Accepted Answer

If a claim is removed from automated processing, it must be reviewed manually. This may involve verifying information, determining medical necessity, or resolving any coding discrepancies. Preauthorization and medical-necessity examination refer to specific types of review that may be required before services are provided or claims are submitted. Claims edit is a general term for automated checks that are performed during processing.

Quiz 16: Explanation of Benefits and Payment Adjudication

An appeal for reconsideration of a carrier's decision on a claim must be made: A)online. B)in writing. C)by phone and in writing. D)with the help of an attorney.

During the patient's care, all procedures and tests are documented on the: A)encounter form. B)explanation of benefits. C)claim form. D)registration form.

The two main methods used by providers to determine their fees are: A)capitation-based and resource-based fee structures. B)profit-based and charge-based fee structures. C)charge-based and resource-based fee structures. D)resource-based and usual-and-customary fee structures.

The steps that result in an insurance carrier's decision to either pay or deny a claim are known as: A)allocation. B)adjudication. C)determination. D)justification.

After a claim is processed, an explanation of benefits (EOB) is sent to the: A)provider only. B)patient only. C)provider and the patient. D)carrier's headquarters.

No matter what amount a provider charges for a given service, each third-party payer will establish the amount they will pay based on what is considered: A)medically appropriate. B)usual and ordinary. C)usual, customary, and reasonable. D)average.

Claims processing involves the verification of medical necessity for the reported procedures; this task is performed by: A)medical office specialists. B)medical directors. C)medical review examiners. D)automated claims processors.

The state official who has regulatory control over insurance carriers and can assist with disputes is the: A)state attorney general. B)state economic development director. C)senior state senator. D)state insurance commissioner.

Resource-based fee structures consider all of the following factors EXCEPT the: A)provider's location. B)work involved. C)overhead (expense) involved. D)malpractice risk.

When providers determine what fee to charge by considering what other providers charge for similar services, this method is: A)charge based. B)research based. C)resource based. D)comparison based.

If no payment is made on a claim by the carrier because the patient has NOT yet satisfied the deductible: A)an EOB is sent to the patient only. B)an EOB is sent to the provider only. C)an EOB is sent to both the patient and the provider. D)no EOB is sent.

When treatment is determined to be appropriate for the diagnosis, the care is considered: A)medically necessary. B)medically appropriate. C)medically reasonable. D)medically feasible.

When a claim has been downcoded or denied by the insurance carrier, the medical office specialist can ask for reconsideration by filing: A)an appeal. B)an adjudication. C)a complaint. D)a request.

When third-party payers determine reimbursement, they consider UCR, which means: A)usual, customary, and reasonable charges. B)usual and common rates. C)uniform, customary reimbursement. D)usual and customary resources.

The first step that the medical office specialist is responsible for before submitting a medical claim is: A)verifying patient insurance benefits. B)obtaining correct and complete patient information. C)entering patient information data into the computer. D)posting charges.

If the reported services are deemed NOT medically necessary at the level reported, the claim will be: A)denied. B)downcoded. C)upcoded. D)pended.

The notification sent by the insurance carrier to the patient and provider after a claim has been processed is known as a(n): A)patient registration form. B)encounter form. C)charge slip. D)explanation of benefits.

A claim that is removed from a payer's automated processing system for additional review is subject to: A)preauthorization. B)manual review. C)medical-necessity examination. D)claims edit.