question

A payer's refusal to pay for a reported procedure that does not meet its medical necessity criteria

answer

medical necessity denial

question

Improper or excessive payments resulting from billing errors for which the provider owes refunds

answer

overpayments

question

Letter from Medicare to an appellant regarding a first-level appeal

answer

Medicare Redetermination Notice

question

Analysis of how long a payer has held submitted claims

answer

Insurance Aging Report

question

Software feature enabling automatic entry of payments on an RA

answer

autoposting

question

Claim status indicating that the payer is waiting for additional information

answer

pending

question

Payer action to gather clinical documentation and study a claim before payment

answer

development

question

A banking service for directly transmitting funds from one bank to another

answer

electronic funds transfer

question

Medical situation in which a patient receives extensive independent care from two or more attending physicians on the same date of service

answer

concurrent care

question

A payer's decision regarding payment of a claim

answer

determination

question

Code used on an RA to indicate the general type of reason code for an adjustment

answer

Claim adjustment group code

question

Federally mandated program that requires private payers to be the primary payers for Medicare beneficiaries' claims

answer

Medicare Secondary Payer (MSP)

question

A payer's initial processing of a claim screens for

answer

basic errors in claim data or missing information

question

Some automated edits are for

answer

patient eligibility, duplicate claims, and non covered services.

question

A claim may be down coded because

answer

the documentation does not justify the level of service.

question

Payers should comply with the required

answer

claim turnaround time.

question

What is the next step after the primary payer's RA has been posted when a patient has additional insurance coverage?

answer

billing the second payer.

question

Appeals must always be filed

answer

with a specified time

question

What type of codes explain Medicare payment decisions?

answer

MOA

question

What appears only on secondary claims

answer

primary payer payment

question

If a patient has secondary insurance under a spouse's plan, what information is needed before transmitting a claim to the secondary plan?

answer

PPO data

question

What should be verified after an RA has been checked for the patient's name, account number, insurance number, and date of service?

answer

the payment for each CPT code matches the expected amount or that all billed CPT codes are listed

question

RA

answer

Remittance Advice

question

MSP

answer

Medicare Secondary Payer

question

a __________________denial may result from a lack of clear, correct linkage between the diagnosis and the procedure

answer

medical necessity

question

The determination of a claim refers to the payer's decision regarding ___

answer

payment

question

a payer may ___ a procedure which it determines was not medically necessary at the level reported

answer

down-code

question

a medical ___ program is established by a third-party payer

answer

review

question

the claims examiner verifies the medical ___ of a providers reported procedures

answer

necessity

question

The HIPAA X835 Health Care Payment and Remittance Advice (HIPAA 835) is the HIPAA mandated transaction for payment explanation. What is the document the beneficiary receives?

answer

EOB

question

For each service line on a claim, the payer makes a determination to decide on which of the following: deny the claim, pay the claim, pay the claim at a reduced level, pay the claim at a higher level

answer

deny the claim, pay the claim, pay the claim at a reduced level

question

When a payment is due for an approved claim, the payer sends which of the following to the provider along with the payment?

answer

Remittance Advice

question

The Accounts Receivable is made up of moneys from which of the following

answer

Money due from the payers and money due from the patients

question

Which of the following are examples of overpayments on claims?

answer

The provider may have collected a primary payment from Medicare when another payer is primary. The claim was paid twice. The claim should have been denied or downcoded because the documentation did not support it.

question

Postpayment reviews are for which of the following?

answer

To verify the medical necessity of reported services, to study treatments and outcomes, to build clinical information, to uncover fraud and abuse

question

PERF PROV

answer

Performing Provider

question

POS

answer

Place of Service Code

question

BILLED

answer

Amount provider billed for the service

question

ALLOWED

answer

Amount payer allows

question

AMT

answer

Amount of adjustments due to group and reason codes

question

List the five steps of the Medicare Appeal Process in correct order

answer

1. Redetermination 2. Reconsideration 3. Administrative law judge 4. Medicare Appeals Council 5. Federal court (judicial review)

question

If a patient is covered by both Medicare and Medicaid, Medicare is

answer

primary

question

When billing the secondary payer for noncrossover claims, the medical insurance specialist prepares an additional claim for the secondary payer and sends it with a copy of what?

answer

Remittance Advice

question

Regulations mandated under the__________________as of January, 2014 require a trace number to appear on both the EFT and its ERA, so the documents are easy to match electronically

answer

Affordable Care Act

question

From the payers point of view, ____________________are improper or excessive payments resulting from billing errors for which the provider owes refunds

answer

overpayments

question

If Medicare is the secondary payer to one primary payer, the claim must be submitted using the___________________transaction unless the practice is excluded from electronic transaction rules.

answer

HIPAA 837P

question

What summarizes the result of the payer's adjudication process?

answer

Remittance Advice (RA)

question

When does a practice not have to send to a secondary payer?

answer

When the claim automatically crosses over and when the primary payer handles the coordination of benefits transaction

question

the payer's processing of claims is called

answer

adjudication

question

a payer 's determination means it is going to

answer

pay, deny, or partially pay the claim

question

a payer's decision regarding whether to pay ,deny , or partially pay a claim is called

answer

determination

question

a payer's automated claim edits may result in claim denial because of

answer

any above

question

a claim that is removed from a payer's automated processing system is sent for

answer

a claim that is removed from a payer's automated processing system is sent for manual review

question

when a claim is pulled by a payer for a manual review ,the provider may be asked to submits.

answer

clinical documentation

question

medical situations in which a patient receives extensive care from two or more providers on the same date of service are called

answer

concurrent care

question

during the adjudication process, if there are problems during the automated review ,the claim is pulled for

answer

development

question

which of these Hippa transaction is sent by a payer to explain a claim payment?

answer

835

question

which of these Hippa transaction is used by medical offices to ask payers about the status of summited claims ?

answer

276

question

A payer's initial claim review may reject a claim due to

answer

an invalid policy number

question

which of these Hippaa transaction is sent by a payer to answer a question about a submitted claim?

answer

277

question

a list of claims transmitted and how long they have been in process with the payer is shown in the

answer

insurance aging report

question

On an aging report ,which category describes a current invoice ?

answer

0-30 days

question

what kind of code appears on payers electronic reports on the progress of transmitted claims in their adjudication process?

answer

claim status category codes

question

If a provider has accepted assignment ,the payer sends the RA/EOB to

answer

the provider

question

the provider has not accepted assignment ,the payer sends the payment to

answer

the patient

question

Remittance advice remark codes are maintained by but can be used by all payers.

answer

CMS

question

The first step the medical billing specialist should check when reviewing RAs/EOBs is to

answer

match up claims with the RA/EOB using the unique claim control number

question

process of means verifying that the totals on the RA/EOB are mathematically correct

answer

reconciliation

question

the first step in the medicare appeals process is

answer

process is re determanation

question

from the payers point of view , are improper or excessive payments resulting from billing errors for which the provider owes refunds.

answer

overpayment

question

If a medical practice believes that it has been treated unfairly by an insurance company, it has the right to file a with the state insurance commission.

answer

grievance

question

IF a patient has additional insurance coverage , after the primary payers RA/EOB has been posted ,the next step is

answer

billing the second payer

question

the medicare secondary payer program coordinates the benefits for patients who have both medicare and

answer

any other insurance coverage

question

If a Medicare beneficiary receives treatment for an accident- related claim ,the medicare plan is

answer

secondary

question

If a medicare beneficiary is employed and covered by the employers group health plan, the medicare plan is

answer

secondary

question

If a medicare beneficiary is covered by a spouses employer group health plan is

answer

second

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