Question 1

Health plan process of examining claims and determining benefits is called _____.

Accepted Answer

Adjudication is the health plan process of examining claims and determining benefits.

Question 2

Adjudication is made up of five steps designed to see how the benefits will be paid. Which of the following is not one of the steps?

Accepted Answer

Adjudication, made up of five steps designed to judge how it should be paid initial processing, automated review, manual review, determination and payment

Question 3

The process of gathering information to begin to adjudicate a claim is called ____.

Accepted Answer

Initial processing is the step of gathering information to adjudicate a claim.

Question 4

The term used by payers to indicate that more information is needed for claim processing is called _____.

Accepted Answer

Development is the term used by payers to indicate that more information is needed for claim processing.

Question 5

Payer's decision about the benefits due for a claim is called ____.

Accepted Answer

Payer's decision about the benefits due for a claim is called determination.

Question 6

Claims may be downcoded because_____.

Accepted Answer

Claims may be downcoded because the documentation fails to support the level of service claimed

Question 7

______ is the use of a procedure code that provides a higher payment.

Accepted Answer

Upcoding is the use of a procedure code that provides a higher payment.

Question 8

What is the name of a transaction that explains payment decisions to the provider?

Accepted Answer

electronic remittance advice (ERA) is a transaction that explains payment decisions to the provider.

Question 9

ERA is the abbreviation for _______.

Accepted Answer

ERA is the abbreviation for electronic remittance advice.

Question 10

Monitoring claims during adjudication requires two types of information: the amount of time the payer is allowed to take to respond to the claim, and ______.

Accepted Answer

Monitoring claims during adjudication requires two types of information. The first is the amount of time the payer is allowed to take to respond to the claim, and the second is how long the claim has been in process.

Question 11

Classification of accounts receivable by length of time is called _____.

Accepted Answer

Aging is the classification of accounts receivable by length of time.

Question 12

________ is a report grouping unpaid claims transmitted to payers by the length of time they remain due.

Accepted Answer

Insurance aging report is a report grouping unpaid claims transmitted to payers by the length of time they remain due.

Question 13

The practice management program is used to generate a report that lists the claims transmitted on each day and shows how long they have been in process with the payer. What is this report called?

Accepted Answer

The practice management program is used to generate an insurance aging report that lists the claims transmitted on each day and shows how long they have been in process with the payer.

Question 14

_____ is the document sent to patients showing how the amount of a benefit was determined.

Accepted Answer

Explanation of benefits (EOB) is a document showing how the amount of a benefit was determined.

Question 15

EOB is the abbreviation for ______.

Accepted Answer

EOB is the abbreviation for explanation of benefits.

Question 16

A (n) ______ explains the adjustment on the insured's account.

Accepted Answer

An adjustment code explains an adjustment on the insured's account.

Question 17

Electronic routing of funds between banks is called ______.

Accepted Answer

Electronic funds transfer (EFT) is electronic routing of funds between banks.

Question 18

Regulations mandated under the Affordable Care Act (ACA) as of January 1, 2014, require a _______ to appear on both the EFT and its ERA, so the documents are easy to match up electronically.

Accepted Answer

Regulations mandated under the Affordable Care Act (ACA) as of January 1, 2014, require a trace number to appear on both the EFT and its ERA, so the documents are easy to match up electronically.

Question 19

The feature in some software packages that automatically posts the payment data in the RA to the correct account is called ____.

Accepted Answer

Instead of posting payments manually, this feature automatically posts the payment data in the RA to the correct account. It is called autoposting.

Question 20

Software feature enabling automatic entry of payments on a remittance advice is called ___.

Accepted Answer

Autoposting is the software feature enabling automatic entry of payments on a remittance advice.

Quiz 13: Claim Processing, Payments, and Collections