question

A HIPAA-mandated electronic transaction for claims may also be called?

answer

HIPAA X12 837 Health Care Claim or Equivalent Encounter Information

question

What organization determines the content of both HIPAA 837 and CMS-1500 claims?

answer

NUCC

question

You need to send a claim to a payer who does not accept electronic claims. Identify the claim form you would use to send a paper claim.

answer

CMS-1500 claim

question

Which of the following skills are required of medical insurance specialists in completing claims?

answer

Organizational skills & good thinking skills

question

What can users do to stay up-to-date with the CMS-1500?

answer

Check the NUCC website for updated instructions

question

Which describes the meaning of transaction "837P"?

answer

Professional

question

Which of the following benefits do medical insurance specialists gain by becoming familiar with the information most often required on claims their practice prepares?

answer

Ability to respond to payers' questions

question

Why has sending paper claims become less common?

answer

The increased use of information technology

question

The electronic transmission of claims is not required by law if a practice never sends any kind of electronic healthcare transactions, and has less than _____ full-time or equivalent employees.

answer

Ten

question

Under HIPAA, payers may not:

answer

Refuse to accept the standard transactions

question

Name the current paper claim approved by the NUCC.

answer

CMS-1500 (08/05)

question

HIPAA EDI transactions are sent via:

answer

5010 version

question

Where is the carrier block located on the CMS-1500?

answer

Upper right

question

Which of the following pieces of information are included in the patient information section of the CMS-1500?

answer

Patient's relationship to insured

question

Name the function of the carrier block.

answer

It allows for a four-line address for the payer

question

Identify the information included in blocks 1 through 13 of the CMS-1500.

answer

Information about the patient and the patient's insurance coverage

question

What item is not included in the patient information section of the CMS-1500?

answer

The diagnosis

question

You are completing a CMS-1500 and realize that a husband has additional coverage under his wife's policy. Determine where you would record the wife's name on the CMS-1500 for the additional insurance.

answer

Item Number 9

question

Name the condition code you would apply to an abortion performed due to social or economic reasons.

answer

AG

question

You are working at a practice and need to decide whether or not you may release a medical document about a patient in order to process a claim. Determine where to find this information on the CMS-1500.

answer

Item Number 12

question

Explain the purpose of Item Number 10A-10C on the CMS-1500.

answer

To determine liability for the condition

question

How current must the signature on file have been obtained for the release of information to be permissable?

answer

Within twelve months

question

What choice may be made in Item Number 6 to show that the insured is the patient?

answer

Self

question

The insured's ID number is the:

answer

Identification number of the policy holder

question

A billing service sending a claim is likely to be the:

answer

Billing provider

question

Identify the person or organization that receives payment.

answer

The pay-to provider

question

The provider who provides the procedure on a claim other than the pay-to provider is called the:

answer

Rendering provider

question

How many different types of providers may need to be identified?

answer

Four

question

If a patient was sent by another physician, that physician is known as the:

answer

Referring physician

question

Examine the following entities and determine which may act as a billing provider.

answer

A clearinghouse, practice, and billing service

question

Assume that three providers are indicated for a claim for lab services. A clearinghouse is the billing provider and the physician practice is the pay-to provider. What type of provider is the laboratory?

answer

The rendering provider

question

The physician who actually provided the service is the:

answer

Rendering provider

question

A legacy (non-NPI) ID number has two parts, the number itself as well as a(n):

answer

Qualifier

question

Section 24 of the CMS-1500 records service line information, which contains the:

answer

Procedures performed for the patient

question

Physicians identify their medical specialty by using:

answer

Taxonomy codes

question

Which of the following codes could be used to indicate that a procedure took place in a medical office?

answer

Place of service codes

question

What type of code may not be required by HIPAA, but if used, must be chosen from the NUCC list?

answer

Administrative codes

question

What is recorded in Section 24 of CMS-1500?

answer

Procedures performed for a patient

question

Determine where you would report a service that was performed by an outside laboratory on the CMS-1500

answer

Item Number 20

question

Correct medical code sets are those that are:

answer

Valid at the time the service was performed

question

Determine which of the following may be a qualifier.

answer

1B

question

A payer requires the provider to list specific identifiers on the CMS-1500. Determine the most likely place they would require this information to be reported.

answer

Item Number 19

question

Name the qualifier used to indicate a provider's taxonomy number.

answer

ZZ

question

Name the qualifier used to indicate a provider plan network identification number.

answer

N5

question

Explain how a payer will respond to a claim that does not contain an ICD-9 (or -10)-CM code.

answer

The payer will deny the claim

question

Discuss the purpose of the shading in the top portions for the six service lines in Section 24 of the CMS-1500 claim form.

answer

To allow for six lines of service

question

You are reporting an unlisted procedure code that requires a very lengthy narrative description. Determine the best way to present this information to the payer.

answer

Provide a special report

question

How many diagnosis pointers can be listed per service line according to the NUCC manual?

answer

Four

question

What type of signatures should usually be used in Item Number 31?

answer

No signature required; leave blank

question

What information might be recorded in Item Number 25?

answer

The physician's or supplier's EIN or SSN

question

Name the POS code used to indicate a procedure occurred in an outpatient hospital.

answer

22

question

Name the POS code used to indicate a procedure occurred in a skilled nursing facility.

answer

31

question

A data element that HIPAA always madates reporting is called a(n):

answer

Required data element

question

A data element that HIPAA mandates reporting under certain conditions is called a(n):

answer

Situational data element

question

Determine what was not required of PMP vendors when the HIPAA 837 electronic transaction was mandated.

answer

Providing updates at no additional cost

question

Name the HIPAA transaction for electronic claims that was generated by physicians.

answer

837 P

question

Name the HIPAA transaction for electronic claims that were generated by hospitals.

answer

847I

question

What are the five sections on a claim?

answer

Provider, subscriber, payer, claim details, services

question

You are working for a practice and need to include a data element on a claim because it is required by the contract with the payer. Determine which of the following data element types need be included in regard to this situation.

answer

NRUC

question

Which of the following is a data element that is required on the HIPAA 837 claim?

answer

The billing provider name and telephone number

question

Under HIPAA, what may happen if the required data elements are not transmitted?

answer

The payer may reject the claim

question

What is the terminology used when the provider must supply the data element on every claim?

answer

Required data element

question

Name the data element that is required for use on the HIPAA 837P in conjunction with CMS Item Number 30.

answer

This data element is "NOT USED"

question

Explain the reason why the five levels of the HIPAA 837 are set up as a hierarchy.

answer

So that when the claim is sent electronically, the only data elements that have to be sent are those that do not repeat previous data.

question

When the subscriber and the patient are the same person, what patient data is required on the HIPAA 837?

answer

The patient data is not required if the subscribed and the patient are the same

question

When the patient and insured are not the same person, what type of code is required to indicate this fact?

answer

Individual relationship code

question

Identify what is indicated by an individual relationship code.

answer

The patient's relationship to the insured

question

On a HIPAA claim, which of the following is assigned to a particular service being reported?

answer

A line item control number

question

On a HIPAA claim, determine which of the following is assigned to a claim by the sender.

answer

Claim control number and line item number

question

What is sent as additional data to support a claim?

answer

Attachment

question

Correct medical code sets for claims are those that are:

answer

Valid at the time the service is provided

question

Correct administrative code sets for claims are those that are:

answer

Valid at the time the transaction is started

question

The responsible party is held accountable for:

answer

The financial responsibility for a bill

question

What does a claim filing indicator code identify?

answer

The type of health plan

question

Identify the claim filing indicator code that is used to indicate a self-pay patient.

answer

09

question

Identify the claim filing indicator code that is used to indicate the the health plan is Medicaid.

answer

MC

question

What is the payer's responsibility sequence number for the payer of last resort?

answer

T

question

You are working at a practice and need to submit a claim, but cannot reach a patient to get their address, which is not on file. Demonstrate the procedure you should follow.

answer

Submit the claim with "Unknown" entered for the patient's address

question

What entity is the destination payer?

answer

The health plan receiving a HIPAA claim

question

You are working at a medical practice and have been requested to resubmit a claim to replace one that was sent the previous week. Determine what claim frequency code should be applied to the claim.

answer

7

question

How many diagnosis codes may be reported on the HIPAA 837?

answer

Twelve

question

How many of the diagnosis codes reported on the HIPAA 837 may be linked to each reported procedure?

answer

Four

question

What information about an accident is not required to be reported on the HIPAA 837 claim?

answer

The name of the person who caused the accident

question

Describe the circumstances under which the last-seen date is not required to be reported on the HIPAA 837 claim.

answer

A physician's services involving routine foot care

question

When nonspecific procedure codes such as unlisted CPT codes are used, the claim must contain:

answer

Service-line level description of the work or drug/dosage

question

In which format can claim attachments be sent?

answer

Electronic or paper format

question

Which of the following payers usually do not require additional data elements?

answer

Fee for services claims

question

Claims that are acceptable for adjudication by payers are called:

answer

Clean claims

question

Identify the important step that immediately proceeds claim transmittal.

answer

Checking the claim

question

Describe the reason for and the process of "dropping to paper."

answer

The practice prints and sends the CMS-1500 paper claim because the payer has not acknowledged receipt of it via electronic transmission

question

Which one of these is not considered to be a common error in generating claims?

answer

Patient name

question

When entering data for a claim, do NOT:

answer

Use hyphens in the telephone numbers, use prefixes in people's name, use a dash in zip code

question

How many major methods are there for transmitting claims electronically?

answer

Three

question

In which of these methods of transmitting claims do providers and payers exchange transactions directly without using a clearinghouse?

answer

Direct transmission to the payer

question

In which of these methods of transmitting claims can employees key standards data elements using an Internet-based service?

answer

Direct data entry

question

Choose the editing software programs sued to check claims for error correction.

answer

Claim scrubbers

question

What is the most common method of claim transmission?

answer

Clearinghouse use

question

Name the electronic format that practices use to ask payers about claims.

answer

HIPAA X12 276/277

question

Using the process of DDE, claims are loaded directly into:

answer

The health plans' computers

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