question

What legislation required all claims sent to the Medicare program be submitted electronically, effective October 16, 2003?

answer

ASCA - Administrative Simplification Compliance Act

question

State the name of the health insurance claim form that was required for use effective April 1, 2014.

answer

The CMS - 1500 Claims Form Revised (02-12)

question

Does Medicare accept the CMS-1500 (02-12) claim form?

answer

Yes

question

What is a pended claim?

answer

Held for payment

question

How many days will it take to process a Medicare claim that is submitted electronically?

answer

14 Days

question

If a claim is submitted on behalf of the patient, and coverage of the services is denied, what is the most effective way to present the situation to the patient?

answer

An official rejection from an insurance company

question

What is dual coverage?

answer

Insured by 2 companies

question

The insurance company with the first responsibility for payment of a bill for medical services is known as the

answer

Primary carrier

question

The CMS-1500 (02-12) claim form allows for reporting of a maximum of ____ diagnosis codes per claim form.

answer

12

question

What Internet resource can be used to find physician provider numbers?

answer

NPI registry

question

For electronic submission of claims, What allows the physician's name to be printed in the signature block where it would normally be signed?

answer

Contract with the third-party payer

question

When preparing a claim that is to be optically scanned, birth dates are keyed in with how many digits?

answer

8 Digits

question

Incomplete claim

answer

Claim missing required information

question

Pending claim

answer

Phrase used when a claim is held back from payment

question

Electronic claim

answer

Claim that is submitted and then optically scanned by the insurance carrier and converted to electronic form

question

Dirty claim

answer

Claim that needs manual processing because of errors or to solve a problem

question

Rejected claim

answer

Claim that needs clarification and answers to some questions

question

Deleted claim

answer

Claim that is cancelled or voided if incorrect claim form is used or itemized charges are not provided

question

Paper claim

answer

Claim that is submitted via telephone line or computer modem

question

Clean claim

answer

Claim that is submitted within the time limit and correctly completed

question

Invalid claim

answer

Medicare claim that contains information that is complete and necessary but is illogical or incorrect

question

Social Security Number

answer

A number issued by the federal government to each individual for personal use

question

National Provider Identifier

answer

A Medicare lifetime provider number

question

Group national provider number

answer

A number listed on a claim when submitting insurance claims to insurance companies under a group name

question

State license number

answer

A number that a physician must obtain to practice in a state

question

Durable medical equipment number

answer

A number used when billing for supplies and equipment

question

Facility provider number

answer

A number issued to a hospital

question

Employer identification number

answer

An individual physician's federal tax identification number issued by the Internal Revenue Service

question

The basic paper claim form currently used by health care professionals and suppliers to bill insurance carriers for services provided to patients is the

answer

CMS-1500 (02-12) claim form

question

What is the exception to the Administrative Simplification Compliance Act's requirement for providers to send claims to Medicare electronically?

answer

Providers with fewer than 10 full-time employees

question

Under ASCA, plans other than Medicare

answer

May allow submission of claims on paper.

question

The National Uniform Claim Committee (NUCC) is made up of

answer

AMA representatives, Centers for Medicare and Medicaid Services representatives, and providers.

question

The first standardized insurance claim form developed in 1958 was known as the

answer

COMB-1

question

The most recently revised version of the 1500 Health Insurance Claim Form developed in 2012 accommodates

answer

Changes in the Electronic Claims Submission Version 5010 837P.

question

If a patient has dual coverage,

answer

Insurance information for both the primary and secondary carriers should be obtained.

question

HIPAA laws require that the provider rendering the service be identified on the claim form by

answer

Reporting of the correct provider number.

question

OBRA requires that Medicare administrative contractors to

answer

Pay interest on all clean claims not paid on time.

question

A claim that is investigated on a postpayment basis that is found to be "not due" will require

answer

Refund of the monies paid.

question

If there is a balance remaining on a patient's account after the patient's primary insurance has paid, and the patient has secondary coverage, the billing specialist should

answer

Send a claim form to the secondary insurance with a copy of the explanation of benefits from the primary carrier.

question

The maximum number of diagnostic codes that can be submitted on the CMS-1500 (02-12) claim form is

answer

Twelve.

question

National Provider Identifier (NPI) numbers are used to report

answer

Referring physicians, ordering physicians, and performing physicians.

question

NPI numbers are assigned

answer

Once in a lifetime, per health care provider.

question

To correct a claim that has been denied because of an invalid procedure code, the billing specialist should

answer

Confirm the code in the CPT manual to ensure it is valid for the date of service.

question

To correct a claim that was denied because more than six lines were entered on the claim,

answer

Bill six claim lines on one claim and complete an additional paper claim for the additional claim lines.

question

T or F. The insurance billing specialist does not need to know how to complete a paper claim because most claims are submitted electronically

answer

False. They sit has to be sent in paper form still need to know how to fill out the paper form in case.

question

T or F. Physicians who experience down times of Internet services that are out of their control for more than 2 days may submit claims to Medicare on paper.

answer

True.

question

T or F. The goal of the NUCC is to provide a warehouse for providers to purchase CMS-1500 claim forms.

answer

False. The goal of the NUCC is the task of standardizing national instructions for completion of the claim form to be used by all payers.

question

T or F. Effective June 1, 2013, providers were required to use only the CMS-1500 claim form (02-12).

answer

False. Effective April 1, 2014, providers were required to use only the CMS-1500 claim form (02-12).

question

T or F. Use of the standardized CMS-1500 claim form has simplified processing of paper claims.

answer

True

question

T or F. Quantities of the CMS-1500 (02-12) claim form can be purchased though CMS or downloaded from the CMS website and used for submission.

answer

False. Quantities of the CMS-1500 (02-12) can be purchased from many medical office supply companies or from the AMA.

question

T or F. Interest rates that apply to the Prompt Payment Interest Rate can be located on the Treasury's Financial Management Service page.

answer

True

question

T or F. Medicare claims that require further investigation before being processed are referred to as "other" claims.

answer

True

question

T or F. A diagnosis should never be submitted without supporting documentation in the medical record.

answer

True

question

T or F. Claims for dated of service in two different years may be submitted on the same claim form.

answer

False. Claims for dates of service in two different years may not be submitted on the same claim form.

question

T or F. Services that are inclusive in the global surgical package that have no charge associated with them should not be submitted on the CMS-1500 claim form.

answer

True

question

T or F. Proofreading claims before submission can prevent denials and delay of claim processing.

answer

True

question

T or F. When submitting supplemental documentation for processing of a claim, the patient's name and date of service need only be on the front of a two-sided document.

answer

False. When submitting supplemental documentation for processing of a claim, the patient's name, subscriber's name (if different from that of the patient), date of service, and insurance identification number needs to be on each side of a two-sided document.

question

T or F. Handwriting is permitted on optically scanned paper claims.

answer

False. Handwriting is not permitted on optically scanned paper claims.

question

T or F. Use the abbreviation "DNA" when information is not applicable.

answer

False. Leave the space black.

Chapter 7 Medical Insurance

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