Question 1

The use of the CMS-1500 claim form is:
A)mandatory for all physician office claims.
B)mandatory for all Medicare claims but optional for private insurance carriers.
C)optional for all Medicare claims but mandatory for private insurance carriers.
D)optional for all physician office claims.

Accepted Answer

The CMS-1500 claim form is mandatory for all Medicare claims but optional for private insurance carriers. This form is specifically designed for non-institutional providers and suppliers to submit claims to Medicare and is widely accepted by private insurers, though not universally required.

Question 2

To submit claims to an insurance carrier, a billing service requires:
A)the patient's personal and insurance information.
B)a copy of the patient's insurance card.
C)the encounter form documenting the diagnosis and services provided.
D)all of the above.

Accepted Answer

All of the above options are required to submit claims to an insurance carrier. The patient's personal and insurance information is needed to verify coverage and ensure accurate billing. A copy of the insurance card is necessary to confirm policy numbers and coverage details. And the encounter form documents the diagnosis and services provided, which is required for proper coding and billing.

Question 3

According to HIPAA, covered entities for compliance issues include:
A)clearinghouses and billing services only.
B)health plans and providers only.
C)health plans, clearinghouses, billing services, and providers.
D)health plans and clearinghouses only.

Accepted Answer

HIPAA defines covered entities as health plans, healthcare providers (including doctors, clinics, hospitals, and nursing homes), and healthcare clearinghouses. In addition, HIPAA also requires compliance from billing services, as they are considered to be business associates of covered entities. Therefore, the best choice is C, which includes all of the entities that must comply with HIPAA regulations.

Question 4

The subsection of HIPAA that regulates electronic billing is known as the:

Accepted Answer

Administrative Simplification.

Question 5

A limited insurance policy purchased to cover part of the patient's expenses, such as coinsurance, for which the patient would otherwise be responsible, is:
A)secondary insurance.
B)supplemental insurance.
C)additional insurance.
D)optional insurance.

Accepted Answer

This policy is known as supplemental insurance as it supplements the existing insurance coverage by covering the patient's out-of-pocket expenses. It is not the primary insurance, but rather a secondary form of insurance that fills in the gaps of coverage left by the primary insurance policy. The other options, such as secondary insurance, additional insurance, and optional insurance, do not accurately describe this type of policy.

Question 6

Components of the Administration Simplification subsection of HIPAA include all of the following EXCEPT:
A)transaction and code sets.
B)compliance and auditing guidelines.
C)uniform identifiers.
D)privacy and security rules.

Accepted Answer

The Administration Simplification provisions of HIPAA include transaction and code sets standards, unique identifiers for providers, and privacy and security rules, but not compliance and auditing guidelines as a direct component. Compliance and auditing are broader aspects that apply to all of HIPAA, not just the Administration Simplification subsection.

Question 7

If needed information is missing from a claim when it is submitted to an insurance carrier, it is referred to as a(n):
A)clean claim.
B)dirty claim.
C)erroneous claim.
D)incomplete claim.

Accepted Answer

A claim missing necessary information when submitted to an insurance carrier is referred to as a "dirty claim." This term is used because the claim has errors or omissions that prevent it from being processed smoothly.

Question 8

If a patient has more than one insurance plan, the determination of how much will be paid by each is known as:
A)assignment of benefits.
B)the birthday rule.
C)coordination of benefits.
D)verification of benefits.

Accepted Answer

When a patient has more than one insurance plan, the coordination of benefits process determines which plan is primary and which is secondary. The primary plan pays first, and the secondary plan covers the remaining costs, up to the limits of the plan. This process is also called "dual coverage" or "multiple coverage." Assignment of benefits refers to patients giving healthcare providers permission to bill insurance directly for services. The "birthday rule" is used to determine which parent's insurance is primary when both parents have coverage for a dependent child. Verification of benefits is the process of confirming a patient's insurance coverage before providing services.

Question 9

As it pertains to the CMS-1500 form, the acronym OCR refers to:
A)the Office of Civil Rights.
B)optical character recognition.
C)optional code references.
D)optical CPT recognition.

Accepted Answer

The answer of As it pertains to the CMS-1500 form,...

Question 10

If an individual is covered under Plan A through her employment and is covered under Plan B through her spouse's employment:
A)Plan A is primary, and Plan B is secondary.
B)Plan B is primary, and Plan A is secondary.
C)only Plan A will pay for her benefits.
D)Plan B will pay all of the benefits.

Accepted Answer

When an individual is covered under two plans, primary and secondary coverage is determined. The primary plan is responsible for paying the benefits first, up to the limits of its coverage. The secondary plan is responsible for paying the remaining costs up to the limits of its coverage. In this scenario, Plan A would be considered the primary plan since it covers the individual based on her own employment. Plan B, which covers the individual based on her spouse's employment, would be considered the secondary plan. Therefore, Plan A would pay for the benefits first, up to the limits of its coverage, and Plan B would pay for any remaining costs up to the limits of its coverage.

Question 11

The CMS-1500 claim form used by physician offices was developed by:
A)the American Medical Association (AMA).
B)the Blue Cross/Blue Shield Association.
C)the Centers for Medicare and Medicaid Services (CMS).
D)representatives from all insurance carriers.

Accepted Answer

The answer of The CMS-1500 claim form used by physician...

Question 12

The employer identification number (EIN) or federal tax ID number is issued by:
A)the Centers for Medicare and Medicaid Services (CMS).
B)the Internal Revenue Service (IRS).
C)the Health Insurance Portability and Accountability Act (HIPAA).
D)insurance carriers.

Accepted Answer

The IRS is responsible for issuing employer identification numbers (EINs) or federal tax ID numbers.

Question 13

The identification number issued to physicians who are authorized to practice medicine in a given state is the:
A)Social Security number.
B)Federal Tax Identification number.
C)state license number.
D)Employer Identification Number.

Accepted Answer

The answer of The identification number issued to physicians who...

Question 14

The CMS-1500 claim form includes the following number of locators (fields):
A)13
B)33
C)52
D)70

Accepted Answer

The answer of The CMS-1500 claim form includes the following...

Question 15

All of the following statements are true about optical character recognition (OCR) devices EXCEPT that they:

Accepted Answer

are used in processing electronic claims.

Question 16

When a patient has more than one insurance policy, one policy is considered the primary coverage and the additional policy is:
A)secondary insurance.
B)supplementary insurance.
C)additional insurance.
D)individual insurance.

Accepted Answer

The answer of When a patient has more than one...

Question 17

Scrambling electronic information during transmission to prevent it from being intercepted or read by unauthorized users is a process known as:
A)electronic data transmission.
B)encryption.
C)optical character recognition (OCR).
D)transcription.

Accepted Answer

The process of scrambling electronic information during transmission to prevent it from being intercepted or read by unauthorized users is known as encryption.

Question 18

If a patient is the primary policyholder on two insurance plans, the primary plan is considered:
A)the plan with the highest level of benefits.
B)the plan in effect for the longest period of time.
C)the plan that has the highest premium.
D)the plan in effect for the shortest period of time.

Accepted Answer

The primary plan is considered to be the one that has been in effect for the longest period of time. This is a standard method used to determine the order of benefits when a patient is covered by multiple insurance policies.

Question 19

According to the birthday rule, if both parents cover dependent children under their insurance policies, the primary insurance is the policy:
A)that has been in force the longest.
B)of the older parent.
C)of the parent whose date of birth occurs earliest in the year.
D)that has the highest level of benefits.

Accepted Answer

The birthday rule in insurance determines the primary insurance for dependent children when both parents have coverage. It states that the parent whose birthday (month and day, not year) comes first in the calendar year has the primary insurance policy for the children. This rule does not consider the year of birth, thereby not necessarily making the older parent's policy primary.

Question 20

When health claims information is exchanged electronically, both the sender and the receiver must follow what HIPAA transaction standard?
A)5010
B)CMS-1500
C)OCR
D)EMC

Accepted Answer

HIPAA transaction standard for exchanging health claims information electronically is 5010.

Quiz 11: Physician Medical Billing

The use of the CMS-1500 claim form is: A)mandatory for all physician office claims. B)mandatory for all Medicare claims but optional for private insurance carriers. C)optional for all Medicare claims but mandatory for private insurance carriers. D)optional for all physician office claims.

To submit claims to an insurance carrier, a billing service requires: A)the patient's personal and insurance information. B)a copy of the patient's insurance card. C)the encounter form documenting the diagnosis and services provided. D)all of the above.

According to HIPAA, covered entities for compliance issues include: A)clearinghouses and billing services only. B)health plans and providers only. C)health plans, clearinghouses, billing services, and providers. D)health plans and clearinghouses only.

The subsection of HIPAA that regulates electronic billing is known as the:

A limited insurance policy purchased to cover part of the patient's expenses, such as coinsurance, for which the patient would otherwise be responsible, is: A)secondary insurance. B)supplemental insurance. C)additional insurance. D)optional insurance.

Components of the Administration Simplification subsection of HIPAA include all of the following EXCEPT: A)transaction and code sets. B)compliance and auditing guidelines. C)uniform identifiers. D)privacy and security rules.

If needed information is missing from a claim when it is submitted to an insurance carrier, it is referred to as a(n): A)clean claim. B)dirty claim. C)erroneous claim. D)incomplete claim.

If a patient has more than one insurance plan, the determination of how much will be paid by each is known as: A)assignment of benefits. B)the birthday rule. C)coordination of benefits. D)verification of benefits.

As it pertains to the CMS-1500 form, the acronym OCR refers to: A)the Office of Civil Rights. B)optical character recognition. C)optional code references. D)optical CPT recognition.

If an individual is covered under Plan A through her employment and is covered under Plan B through her spouse's employment: A)Plan A is primary, and Plan B is secondary. B)Plan B is primary, and Plan A is secondary. C)only Plan A will pay for her benefits. D)Plan B will pay all of the benefits.

The CMS-1500 claim form used by physician offices was developed by: A)the American Medical Association (AMA). B)the Blue Cross/Blue Shield Association. C)the Centers for Medicare and Medicaid Services (CMS). D)representatives from all insurance carriers.

The employer identification number (EIN) or federal tax ID number is issued by: A)the Centers for Medicare and Medicaid Services (CMS). B)the Internal Revenue Service (IRS). C)the Health Insurance Portability and Accountability Act (HIPAA). D)insurance carriers.

The identification number issued to physicians who are authorized to practice medicine in a given state is the: A)Social Security number. B)Federal Tax Identification number. C)state license number. D)Employer Identification Number.

The CMS-1500 claim form includes the following number of locators (fields): A)13 B)33 C)52 D)70

All of the following statements are true about optical character recognition (OCR) devices EXCEPT that they:

When a patient has more than one insurance policy, one policy is considered the primary coverage and the additional policy is: A)secondary insurance. B)supplementary insurance. C)additional insurance. D)individual insurance.

Scrambling electronic information during transmission to prevent it from being intercepted or read by unauthorized users is a process known as: A)electronic data transmission. B)encryption. C)optical character recognition (OCR). D)transcription.

If a patient is the primary policyholder on two insurance plans, the primary plan is considered: A)the plan with the highest level of benefits. B)the plan in effect for the longest period of time. C)the plan that has the highest premium. D)the plan in effect for the shortest period of time.

When health claims information is exchanged electronically, both the sender and the receiver must follow what HIPAA transaction standard? A)5010 B)CMS-1500 C)OCR D)EMC