Deck 4: Processing an Insurance Claim

Question 1

Which is a manual permanent record of all financial transactions between the patient and the practice?

A) health record
B) insurance claim
C) patient ledger
D) remittance advice

Answer 1

patient ledger

Question 2

A nonparticipating provider (nonPAR) is an out-of-network provider who does not contract with the insurance plan, and patients who elect to receive care from non-PARs will incur higher out-of-pocket expenses. The patient __________ expected to pay the difference between the insurance payment and the provider's fee.

A) is not
B) is usually

Answer 2

is usually

Question 3

Which person is responsible for paying the charges?

A) enrollee
B) guarantor
C) patient
D) payer

Answer 3

guarantor

Question 4

A child is listed as a dependent on both his father's and his mother's group insurance policies. The father's birth date is March 20, 1977, and the mother's birth date is March 6, 1979. Which policy is primary?

A) father's policy
B) mother's policy

Question 5

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.

A) are
B) are not

Question 6

Which is a computerized permanent record of all financial transactions between the patient and the practice?

A) health record
B) patient account record
C) patient ledger
D) remittance advice

Question 7

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

A) accounts receivable management
B) claims submission and adjudication
C) coordination of benefits
D) delinquent claims processing

Question 8

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

A) $10
B) $20
C) $30
D) $40

Question 9

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.

A) $10
B) $20
C) $30
D) $40

Question 10

Which means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim?

A) accept assignment
B) assignment of benefits

Question 11

Which is the electronic or manual transmission of claims data to payers or clearinghouses for processing?

A) claims adjudication
B) claims payment
C) claims processing
D) claims submission

Question 12

The manual daily accounts receivable journal is also known as the __________, and it is a chronologic summary of all transactions posted to individual patient ledgers/accounts on a specific date.

A) day sheet
B) explanation of benefits
C) patient ledger
D) superbill

Question 13

Which is the insurance plan responsible for paying health care insurance claims first?

A) primary insurance
B) secondary insurance
C) supplemental insurance
D) tertiary insurance

Question 14

Which is the financial record source document used by health care providers and other personnel in a hospital outpatient setting to select codes for treated diagnoses and services rendered to the patient during the current visit?

A) chargemaster
B) explanation of benefits
C) remittance advice
D) superbill

Question 15

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

A) longest
B) shortest

Question 16

Which is the financial record source document used by health care providers and other personnel in a physician's office setting to record treated diagnoses and services rendered to the patient during the current visit?

A) CMS-1500 claim
B) explanation of benefits
C) remittance advice
D) superbill

Question 17

Which is the financial record source document used by health care providers and other personnel to record treated diagnoses and services rendered to the patient during the current visit?

A) CMS-1500 claim
B) encounter form
C) explanation of benefits
D) remittance advice

Question 18

Health insurance plans may include a(n) __________ provision, which means that when the patient has reached that limit for the year, appropriate patient reimbursement to the provider is determined.

A) assignment of benefits
B) coinsurance and copayment
C) deductible
D) out-of-pocket payment

Question 19

Secondary insurance is the insurance plan that is billed after the primary insurance plan has paid its contracted amount and the provider's office has received a(n) __________ from the primary payer.

A) CMS-1500 claim
B) encounter form
C) explanation of benefits
D) remittance advice

Question 20

When a child lives with both parents, and each parent subscribes to a different health insurance plan, the primary and secondary policies are determined by applying the birthday rule. The individual who holds the primary policy for dependent children is the spouse whose birth __________.

A) day occurs earlier in the month
B) month and day occur earlier in the calendar year
C) month, day, and year occur earlier
D) year occurs earlier

Question 21

Coordination of benefits (COB) is a provision in __________ health insurance policies intended to keep multiple insurers from paying benefits covered by other policies.

A) all
B) commercial
C) group
D) private

Question 22

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.

A) approved
B) denied
C) submitted
D) unauthorized

Question 23

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) common data file
B) electronic media claim
C) patient ledger
D) source document

Question 24

When selecting a clearinghouse, providers may also want to determine whether it is accredited by the __________.

A) Centers for Medicare and Medicaid Services
B) Electronic Healthcare Network Accreditation Commission
C) Joint Commission
D) National Committee for Quality Assurance

Question 25

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.

A) clean
B) electronic
C) submitted
D) unassigned

Question 26

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

A) coinsurance
B) copayment
C) deductible
D) premium

Question 27

A claims attachment is __________ documentation associated with a health care claim or patient encounter.

A) coding
B) payment
C) remittance
D) supporting

Question 28

Any procedure or service reported on the claim that is not included on the master benefit list is a noncovered benefit and will result in claims __________.

A) approval
B) denial
C) payment
D) submission

Question 29

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.

A) chargemaster
B) common data file
C) encounter form
D) list of pre-existing conditions

Question 30

Which is the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid?

A) coinsurance
B) copayment
C) deductible
D) premium

Question 31

A clearinghouse that involves value-added vendors, such as banks, in the processing of claims is called a value-added __________ to improve efficiency and reduce expenses.

A) network
B) organization
C) reseller
D) system

Question 32

A policyholder or __________ is the person in whose name the insurance policy is issued.

A) beneficiary
B) employee
C) patient
D) provider

Question 33

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.

A) $20; $80
B) $50; $50
C) $80; $20
D) $100; $20

Question 34

Which is the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits?

A) coinsurance
B) copayment
C) deductible
D) premium

Question 35

Covered entities are required to use mandated national standards when conducting any of the defined transactions covered under HIPAA. Which is an example of a covered entity?

A) banks that handle medical office payroll
B) companies that performs human resources
C) ERISA-covered health benefit plans
D) outsourced physical plant management

Question 36

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.

A) allowed
B) denied
C) inconsistent
D) irregular

Question 37

The computer-to-computer transfer of data between providers and third-party payers (or providers and health care clearinghouses) in a data format agreed upon by sending and receiving parties is called electronic __________.

A) data interchange
B) flat file format
C) media claim
D) remittance advice

Question 38

Which involves sorting claims upon submission to collect and verify information about the patient and provider?

A) claims adjudication
B) claims payment
C) claims processing
D) claims submission

Question 39

Which is an electronic format supported for health care claims transactions?

A) ANSI ASC X12 837
B) CMS-1500 claim
C) national drug code format
D) UB-04 claim

Question 40

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?

A) claims adjudication
B) claims payment
C) claims processing
D) claims submission

Question 41

Providers have the option of arranging for __________, which means that payers deposit reimbursement for health care services to the provider's account electronically.

A) electronic data interchange
B) electronic flat file formats
C) electronic funds transfer
D) electronic media claims

Question 42

The patient underwent office surgery on March 18, and the third-party payer determined the allowed charge to be $1,480. The patient paid the 20 percent coinsurance at the time of the office surgery. The physician and patient each received a check for $1,184, and the patient signed her check over to the physician. The overpayment was __________, and the physician must reimburse the third-party payer.

A) $296
B) $1,184
C) $1,480
D) $2,368

Question 43

Medicare calls its remittance advice a(n) __________.

A) explanation of benefits
B) electronic remittance advice
C) Medicare summary notice
D) provider remittance notice

Question 44

Which amended the Truth in Lending Act and requires prompt written acknowledgment of consumer billing complaints and investigation of billing errors by creditors?

A) Fair Credit and Charge Card Disclosure Act
B) Fair Credit Billing Act
C) Fair Credit Reporting Act
D) Fair Debt Collection Practices Act

Question 45

A remittance advice submitted to the provider electronically is called an electronic remittance advice (ERA), and __________.

A) different information is included as compared with a paper-based remittance advice
B) it contains identical information to the information on a paper-based remittance advice
C) payers are required to increase the amount of reimbursement paid to the provider
D) similar information is included in the exact format as a paper-based remittance advice

Question 46

Which claims are filed according to year and insurance company and include those for which all processing, including appeals, has been completed?

A) clean claims
B) closed claims
C) open claims
D) unassigned claims

Question 47

Which protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services?

A) Fair Credit and Charge Card Disclosure Act
B) Fair Credit Billing Act
C) Fair Credit Reporting Act
D) Fair Debt Collection Practices Act

Question 48

A pre-existing condition is any medical condition that was diagnosed and/or treated within a specified period of time __________ the enrollee's effective date of coverage.

A) after
B) before

Question 49

A delinquent account is also called a __________ account, which means it is one that has not been paid within a certain time frame (e.g., 120 days). Following up on such delinquent accounts is crucial to the success of the business.

A) deductible
B) deficient
C) past-due
D) payable

Question 50

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

A) addendum to the patient record to justify
B) letter signed by the provider explaining
C) patient release of information form describing
D) resubmitted CMS-1500 insurance claim indicating

Question 51

Which is considered a financial source document from which an insurance claim is generated?

A) CMS-1500 claim
B) encounter form
C) ledger card
D) patient record

Question 52

The delinquent claim cycle advances through aging periods, and providers typically focus __________ recovery efforts for older delinquent claims.

A) external
B) internal

Question 53

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)?

A) Electronic Funds Transfer Act
B) Equal Credit Opportunity Act
C) Fair Credit Billing Act
D) Truth in Lending Act

Question 54

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

A) closed claims
B) clean claims
C) open claims
D) unassigned claims

Question 55

Which prohibits discrimination on the basis of race, color, religion, national origin, sex, marital status, age, receipt of public assistance, or good-faith exercise of any rights under the Consumer Credit Protection Act?

A) Electronic Funds Transfer Act
B) Equal Credit Opportunity Act
C) Fair Debt Collection Practices Act
D) Truth in Lending Act

Question 56

Which claims are organized by year and are generated for providers who do not accept assignment?

A) clean claims
B) closed claims
C) open claims
D) unassigned claims

Question 57

Which states that third-party debt collectors are prohibited from employing deceptive or abusive conduct in the collection of consumer debts incurred for personal, family, or household purposes?

A) Fair Credit and Charge Card Disclosure Act
B) Fair Credit Billing Act
C) Fair Credit Reporting Act
D) Fair Debt Collection Practices Act

Question 58

Which are the amounts owed to a business for services or goods provided?

A) accounts payable
B) accounts receivable
C) allowed charges
D) assignment of benefits

Question 59

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

A) Electronic Funds Transfer Act
B) Equal Credit Opportunity Act
C) Fair Credit and Charge Card Disclosure Act
D) Fair Credit Billing Act

Question 60

Which amended the Truth in Lending Act and requires credit and charge card issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open-ended credit and charge accounts and under other circumstances?

A) Fair Credit and Charge Card Disclosure Act
B) Fair Credit Billing Act
C) Fair Credit Reporting Act
D) Fair Debt Collection Practices Act

Question 61

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.

A) destroy
B) remotely file
C) outsource
D) suspend

Question 62

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

A) adjudication
B) litigation
C) mediation
D) subrogation

Question 63

Which is the practice of submitting multiple CPT codes when just one code should have been submitted?

A) downcoding
B) jamming
C) unbundling
D) upcoding

Question 64

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 __________.

A) deposited in the bank via electronic funds transfer
B) previously included in the provider's income
C) received from the third-party payer or patient
D) turned over to a collections agency for processing

Question 65

Which is the assignment of lower-level codes than documented in the record?

A) downcoding
B) jamming
C) unbundling
D) upcoding

Question 66

When dealing with delinquent claims, it is important to review records to determine whether the claim was paid, was denied, or is pending. A pending claim is considered in __________.

A) adjudication
B) denial
C) receipt
D) suspense

Question 67

One reason to track unpaid claims is due to the payment error in which a patient erroneously cashes a check made out to both patient and provider, which is called a __________.

A) combination check
B) credit check
C) third-party payer check
D) two-party check