Exam 4: Processing an Insurance Claim

Claims adjudication involves making a determination about __________ charges, which is the maximum amount the payer will permit for each procedure or service, according to the patient's policy.

Which person is responsible for paying the charges?

The claim is also checked against the __________, which is an abstract of all recent claims filed on each patient and helps determine whether the patient is receiving concurrent care for the same condition by more than one provider.

When applying the birthday rule, if policyholders have identical birthdays, the policy in effect the __________ is considered primary.

Dr. Jones is a nonparticipating provider (nonPAR) for the ABC Health Insurance Plan. Anne Smith is treated by Dr. Jones in the office, for which a $100 fee is charged. Given the information in the table located below, calculate the nonPAR provider write-off amount.

Which is a legal action that can be used to recover a debt and is usually a last resort for a medical practice?

Which is the fixed amount the patient pays each time he or she receives health care services?

Many physician practices contract out or __________ the delinquent accounts to a full-service collections agency that utilizes collection tactics, including written contacts and multiple calls from professional collectors.

An account receivable that cannot be collected by the provider or a collection agency is called a bad debt. To deduct a bad debt, the amount must have been __________.

Which claims are organized by month and insurance company after submission to the payer, but for which processing is not complete?

Which best assists providers in the overall collection of appropriate reimbursement for services rendered?

Which requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions (including disclosing finance charges expressed as an annual percentage rate)?

An appeal is documented as a(n) __________ why a claim should be reconsidered for payment.

Electronic claims are submitted directly to the payer after being checked for accuracy by billing software or a health care clearinghouse, which results in a __________ claim that contains all required data elements needed to process and pay the claim.

Which involves comparing the claim to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures performed or services provided are covered benefits?

Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization, are called __________ services.

Which establishes the rights, liabilities, and responsibilities of participants in electronic fund transfer systems?

Clearinghouses process claims in an electronic flat file format, which requires conversion of CMS-1500 claims data to a standard format. Providers can also use software to convert claims to an electronic flat file format, also known as a(n) __________, which is a series of fixed-length records (e.g., 25 spaces for patient's name) submitted to payers as a bill for health care services.

A participating provider (PAR) contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed. This means that PARs __________ allowed to bill patients for the difference between the contracted rate and their normal fee.

Sally Simmons is a patient of Dr. Tyler's. She received preventive services for her annual physical examination on May 17. The third-party payer determined the allowed charge for preventive services to be $100, for which the payer reimbursed the physician 80 percent of that amount. Sally is responsible for paying the remaining 20 percent directly to the physician. Thus, the physician will receive a check in the amount of __________ from the payer, and the patient will pay __________ to the physician.