question

The _____________ of a claim refers to the payer's decision regarding payment.

answer

determination

question

A __________occurs when a procedure and a diagnosis are not correctly linked, in the opinion of the payer.

answer

medical necessity denial

question

A payer may _________ a procedure which it determines was not medically necessary at the level reported.

answer

downcode

question

What is the claim status when the payer is developing the claim?

answer

suspended

question

The term ______________ during claim adjudication means that the payer needs more information to process the claim.

answer

development

question

Concurrent care is care provided:

answer

to a patient on the same date at the same place of service by two or more physicians

question

A pending claim is indicated by which claim status category code?

answer

P

question

A finalized claim is indicated by which claim status category code?

answer

F

question

An aging report groups unpaid claims or bills according to:

answer

the length of time that they remain due

question

A typical aging report groups payments that are due into which of these categories?

answer

0-30 days, 31-60 days, 61-90 days, and over 90 days.

question

An __________ code indicates that a request for more information has been sent.

answer

R

question

What code indicates an error has occurred in transmission?

answer

E

question

A(n) ________ claim status category code is an acknowledgment that the claim has been received.

answer

A

question

A paper explanation of benefits (EOB) is sent to patients by payers after claims:

answer

are paid

question

The payer's RA shows:

answer

both the amount the provider is allowed and the amount patient pays

question

RA is the abbreviation for:

answer

remittance advice

question

Claim adjustment reason codes are used by payers to explain entries in:

answer

RAs

question

When a payer's RA is received, the medical insurance specialist:

answer

checks that the amount paid matches the expected payments

question

EFT is the abbreviation for:

answer

electronic funds transfer

question

______________ is a feature of some medical billing programs that automatically records payments in the correct accounts.

answer

Autoposting

question

Funds that are electronically transferred from a payer are directly deposited in the:

answer

practice's bank account

question

When is an appeal sent to third-party payers?

answer

after a claim is rejected or paid at less than the expected amount

question

The __________ is the person or entity who seeks to receive benefits via an appeal.

answer

claimant

question

How many steps are there in the Medicare appeal process?

answer

five

question

What does the abbreviation COB stand for?

answer

Coordination of benefits

question

If a patient has additional insurance coverage, after the primary payer's RA has been posted, the next step is:

answer

billing the second payer

question

Which of the following statements is true?

answer

Medicaid is the secondary payer to Medicare

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

answer

manual review

question

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

answer

development

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

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

answer

the provider

question

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

answer

the patient

question

The process of ________________ means verifying that the totals on the RA are mathematically correct.

answer

reconciliation

question

The person filing an appeal is known as a(n) ______________________, regardless of whether that individual is a provider or a patient.

answer

both claimant and appellant

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 is employed and covered by the employer's group health plan, the Medicare plan is

answer

secondary

question

If a Medicare beneficiary is covered by a spouse's employer group health plan, the Medicare plan is

answer

secondary

question

What is the correct order for the basic steps of a payer's adjudication process?

answer

initial processing, automated review, manual review, determination, and payment.

Medical Insurance Billing Chapter 13 Quiz – Flashcards

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