Question 1

The typical _______________ payment structure is where a provider will bill for all services rendered to the third-party payer after the services have been provided and then the third-party payer, retrospectively, will pay the provider.
A) fee-for-service
B) episode-of-care
C) block payment
D) capitation

Accepted Answer

The typical fee-for-service payment structure involves billing for each service provided to a patient after the services have been rendered, and then the third-party payer pays the provider retrospectively for those services.

Question 2

Currently, we are in a prospective payment environment and have various forms of payment, such as:
A) managed care.
B) episode-of-care.
C) capitation.
D) global payment.
E) All of these are correct.

Accepted Answer

All of these options (managed care, episode-of-care, capitation, and global payment) are forms of payment in a prospective payment environment, where payments are predetermined rather than based on the volume of care provided.

Question 3

For pricing purposes, the ANSI X12N 837 P (837P) Electronic Claim Form, when the Place of Service (POS) is listed as __________, and the pricing will be based on where the beneficiary's home is located.
A) 10
B) 11
C) 12
D) 24
E) None of these is correct.

Accepted Answer

The Place of Service (POS) code 12 indicates services provided in the beneficiary's home, which is why pricing is based on the beneficiary's home location.

Question 4

If ____________ ambulance(s) transported the patient from the initial pick-up location to the final destination, the jurisdiction is with the carrier that is at the point of origin of the ambulance.
A) three
B) two
C) one
D) None of these is correct.

Accepted Answer

When only one ambulance is involved in transporting the patient from the initial pick-up location to the final destination, the jurisdiction for billing or regulatory purposes lies with the carrier that is at the point of origin of the ambulance service.

Question 5

Carrier jurisdiction for claims involving individuals who are part of the Railroad Retirement Beneficiary includes those who are entitled to both ______________ and railroad retirement benefits.
A) Medicare
B) Medicaid
C) Blue Cross and Blue Shield
D) Social Security
E) None of these is correct.

Accepted Answer

Individuals who are part of the Railroad Retirement Beneficiary and are entitled to both railroad retirement benefits and Social Security fall under the carrier jurisdiction for claims.

Question 6

The agency or facility providing the care to the patient will be responsible for payment of the supplies that are covered under Part B, as they are covered under the payment for:
A) Prospective Payment System (PPS).
B) Diagnosis-Related Group (DRG).
C) Ambulatory Payment Classification (APC).
D) Home Health Resource Groups (HHRG).

Accepted Answer

The Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment for supplies covered under Part B is included in the PPS payment to the agency or facility providing care.

Question 7

Charges to the beneficiary for admission or readmission are not allowable, however, there is an exception when a resident leaves a skilled nursing facility (SNF):
A) against medical advice.
B) temporarily.
C) upon discharge to home.
D) None of these is correct.

Accepted Answer

Charges to the beneficiary for admission or readmission to a skilled nursing facility (SNF) are generally not allowed. However, an exception exists when a resident leaves the SNF temporarily and then is readmitted. This scenario can involve situations where the resident might leave for a short period for personal reasons but intends to return to the SNF.

Question 8

A financial relationship includes both ownership and investment interests, along with compensation arrangements that include contractual arrangements between a ____________________ and ______________________ for physician services.
A) a hospital and a Health Maintenance Organization (HMO)
B) a physician and a Physician-Hospital Organization (PHO)
C) a hospital and a physician
D) a Managed Care Organization (MCO) and a PHO

Accepted Answer

A financial relationship can exist between a hospital and a physician, encompassing both ownership/investment interests and compensation arrangements, including contracts for physician services.

Question 9

The Advance Beneficiary Notice (ABN) cannot have italics or any font that is difficult to read and must be:
A) at least 12-point font size.
B) in dark ink.
C) legibly handwritten.
D) All of these are correct.
E) None of these is correct.

Accepted Answer

The Advance Beneficiary Notice (ABN) guidelines specify that the document must be easily readable to ensure the recipient understands the information provided. This includes using at least a 12-point font size, printing in dark ink for clarity, and allowing for legible handwriting if the notice is not typed, making all these options correct requirements for an ABN.

Question 10

A(n) __________________ is a beneficiary who can comprehend the notice.
A) capable recipient
B) incompetent person
C) comatose person
D) person under duress

Accepted Answer

A capable recipient is someone who has the mental capacity to understand the notice they are receiving, making them the correct choice.

Question 11

ABNs given to a patient or authorized representative who is under _______________ cannot be considered a proper notice.
A) great duress
B) a non-emergent situation
C) both great duress and a non-emergent situation
D) None of these is correct.

Accepted Answer

ABNs (Advance Beneficiary Notices) given to a patient or authorized representative who is under great duress cannot be considered proper notice because the patient may not be in a position to fully understand or make informed decisions about their care.

Question 12

A request for redetermination must be filed within ____ days after receiving the notice of the initial determination.
A) 90
B) 60
C) 120
D) 180

Accepted Answer

The answer of A request for redetermination must be filed...

Question 13

The appeals process consists of ____________ levels; each level must be completed for each claim at issue prior to proceeding to the next level.
A) four
B) three
C) five
D) six

Accepted Answer

The appeals process consists of five levels. These levels are designed to ensure that every claim gets a thorough review, and each level must be completed before moving on to the next. This structured approach allows for multiple opportunities to review and potentially overturn initial decisions.

Question 14

An appeal letter should be formatted in all of the following ways, except:
A) spell out all dates.
B) use a small font size no larger than 10.
C) use bullet points.
D) spell out procedures.

Accepted Answer

Using a small font size no larger than 10 is not recommended for appeal letters. It's important to use a readable font size, typically between 10.5 to 12 points, to ensure the letter is easy to read.

Question 15

A supplier is a physician or other practitioner, or an entity other than a provider who furnishes healthcare services under Medicare, and must meet certain requirements as outlined in the Medicare Program Integrity Manual.

Accepted Answer

A supplier in the context of Medicare is indeed defined as a physician, practitioner, or an entity other than a provider that furnishes healthcare services under Medicare. They must meet specific requirements as outlined in the Medicare Program Integrity Manual to ensure compliance and integrity within the Medicare program.

Question 16

When not using the POS 12, the claim processing and pricing calculations will be based on the service location.

Accepted Answer

When not using Place of Service (POS) code 12, which indicates home location, claim processing and pricing calculations default to the physical location where services are rendered, as the POS code indicates the setting in which services were provided.

Question 17

If a supplier operates mobile units for X-ray and other portable services in multiple MAC DMEs, then the permanent address for where the beneficiary received services will determine which carrier will process the claim.

Accepted Answer

The permanent address of the beneficiary is used to determine the appropriate carrier for processing claims when services are provided by mobile units across different MAC DMEs.

Question 18

In the agreement/attestation statement signed by a provider, it agrees to charge Medicare beneficiaries for any services which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program.

Accepted Answer

The agreement/attestation statement typically requires providers to agree not to charge Medicare beneficiaries for any services covered by Medicare, except for applicable coinsurance and deductibles.

Question 19

In the provider agreement between CMS and the provider, the provider agrees to promptly refund any money that they incorrectly collected from the Medicare beneficiary.

Accepted Answer

In the provider agreement with CMS (Centers for Medicare & Medicaid Services), providers agree to refund any overpayments or incorrect charges to Medicare beneficiaries promptly, ensuring compliance with Medicare rules and protecting beneficiaries from incorrect billing.

Quiz 3: Introduction to Claims Processing

The typical _______________ payment structure is where a provider will bill for all services rendered to the third-party payer after the services have been provided and then the third-party payer, retrospectively, will pay the provider.

Currently, we are in a prospective payment environment and have various forms of payment, such as:

For pricing purposes, the ANSI X12N 837 P (837P) Electronic Claim Form, when the Place of Service (POS) is listed as __________, and the pricing will be based on where the beneficiary's home is located.

If ____________ ambulance(s) transported the patient from the initial pick-up location to the final destination, the jurisdiction is with the carrier that is at the point of origin of the ambulance.

Carrier jurisdiction for claims involving individuals who are part of the Railroad Retirement Beneficiary includes those who are entitled to both ______________ and railroad retirement benefits.

The agency or facility providing the care to the patient will be responsible for payment of the supplies that are covered under Part B, as they are covered under the payment for:

Charges to the beneficiary for admission or readmission are not allowable, however, there is an exception when a resident leaves a skilled nursing facility (SNF) :

A financial relationship includes both ownership and investment interests, along with compensation arrangements that include contractual arrangements between a and __ for physician services.

The Advance Beneficiary Notice (ABN) cannot have italics or any font that is difficult to read and must be:

A(n) __________________ is a beneficiary who can comprehend the notice.

ABNs given to a patient or authorized representative who is under _______________ cannot be considered a proper notice.

A request for redetermination must be filed within ____ days after receiving the notice of the initial determination.

The appeals process consists of ____________ levels; each level must be completed for each claim at issue prior to proceeding to the next level.

An appeal letter should be formatted in all of the following ways, except:

A supplier is a physician or other practitioner, or an entity other than a provider who furnishes healthcare services under Medicare, and must meet certain requirements as outlined in the Medicare Program Integrity Manual.

When not using the POS 12, the claim processing and pricing calculations will be based on the service location.

If a supplier operates mobile units for X-ray and other portable services in multiple MAC DMEs, then the permanent address for where the beneficiary received services will determine which carrier will process the claim.

In the agreement/attestation statement signed by a provider, it agrees to charge Medicare beneficiaries for any services which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program.

In the provider agreement between CMS and the provider, the provider agrees to promptly refund any money that they incorrectly collected from the Medicare beneficiary.