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Chapter 7: The Paper Claim CMS-1500 (02-12)

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What legislation required all claims sent to the Medicare program be submitted electronically, effective October 16, 2003?
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Congress- the
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State the name of the health insurance claim form that was required for use effective April 1, 2014.
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CMS-1500 (02-12)
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Does Medicare accept the CMS-1500 (02-12) claim form?
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Yes
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What is a pended claim?
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A claim that is held in suspense for review or other reasons by the third-party payer
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How many days will it take to process a Medicare claim that is submitted electronically?
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14 days
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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?
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Send/show them the official rejection statement from the insurance company
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What is dual coverage?
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When a patient had more than one insurance company’s coverage
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The insurance company with the first responsibility for payment of a bill for medical services is known as the..
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Primary carrier
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The CMS-1500 (02-12) claim form allows for reporting of a maximum of ______ diagnosis codes per claim form.
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12
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What Internet resource can be used to find physician provider numbers?
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The State licensing board website
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For electronic submission of claims, what allows the physician’s name to be printed in the signature block where it would normally be signed?
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The participating contract with the third-party payer that the physician has physically signed
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When preparing a claim that is to be optically scanned, birth dates are keyed in with how many digits?
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8- MMDDYYYY
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1.Claim missing required information 2. Phrase used when a claim is held back from payment 3. Claim that is submitted and then optically scanned by the insurance carrier and converted to electronic form 4. Claim that needs manual processing because of errors or to solve a problem 5. Claim that needs clarification and answers to some questions 6. Claim that is canceled or voided if incorrect claim form is used or itemized charges are not provided 7. Claim that is submitted via telephone line or computer modem 8. Claim that is submitted within the time limit and correctly completed 9. Medicare claim that contains information that is complete and necessary but is illogical or incorrect
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1. h- incomplete claim 2. f- pending claim 3. b- paper claim 4. d- dirty claim 5. g- rejected claim 6. i- incomplete claim 7. e- electronic claim 8. a- clean claim 9. c- invalid claim
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1. a number issued by the federal ggovernment to each individual for personal use 2. a Medicare lifetime provider number 3. a number listed on a claim when submitting insurance claims to insurance companies under a group name 4. a number that a physician must obtain to practice in a state 5. a number used when billing for supplies and equipment 6. a number issued to a hospital 7. an individual physician’s federal tax identification number issued by the Internal Revenue Service
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1. c- Social Security Number 2. e- National Provider Identifier 3. d- Group national provider number 4. a- State license number 5. f- durable medical equipment number 6. g- facility provider number 7. b- employer identification number
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The basic claim form currently used by health care professionals and suppliers to bill insurance carriers for services provided to patients is the…
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b. CMS-1500 (02-12) claim form
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What is the exception to the Administrative Simplification Compliance Act’s (ASCA’s) requirement for providers to send claims to Medicare electronically?
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c. providers with fewer than 10 full-time employees
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Under ASCA, plans other than Medicare
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a. may allow submissions of claims on paper
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the National Uniform Claim Committee (NUCC) is made up of
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d. all of the above
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The first standardized insurance claim form developed in 1958 was known as the
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d. COMB-1
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The most recently revised version of the 1500 Health Insurance Claim Form developed in 2012 accommodates
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c. changes in the Electronic Claims Submission Version 5010 837P
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If a patient has dual coverage,
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b. insurance information for both the primary and the secondary carrier should be obtained
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Health Insurance Portability and Accountability Act (HIPAA) laws require that the provider rendering the service be identified on the claim form by
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a. reporting of the correct provider number
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The Omnibus Budget Reconciliation Act (OBRA) requires Medicare administrative contractors to
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d. pay interest on all clean claims not paid on time
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A claim that is investigated on a postpayment basis that is found to be “not due” will require
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c. refund of all the monies paid
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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
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c. send a claim form to the secondary insurance with a copy of the EOB from the primary carrier
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The maximum number of diagnostic codes that can be submitted on the CMS-1500 (02-12) claim form is
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d. twelve
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The National Provider Identifier (NPI) numbers are used to report
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d. all of the above
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NPI numbers are assigned
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a. once in a lifetime, per health care provider
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To correct a claim that has been denied because of an invalid procedure code, the billing specialist should
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b. confirm the code in the CPT manual to ensure it is valid for the date of service
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To correct a claim that was denied because more than six lines were entered on the claim
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c. bill six claim lines on one claim and complete an additional paper claim for the additional claim lines
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The insurance billing specialist does not need to know how to complete a paper claim because most claims are submitted electronically
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False
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Physicians who experience downtimes of Internet services that are out of their control for more than 2 days may submit claims to Medicare on paper
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True
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the goal of the NUCC is to provide a warehouse for providers to purchase CMS-1500 claim forms
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False
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Effective June 1, 2013, providers were required to use only the CMS-1500 (02-12) claim form
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False
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Use of the standardized CMS-1500 (02-12) claim form has simplified processing of paper claims
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True
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Quantities of the CMS-1500 (02-12) claim form can be purchase through CMS or downloaded from the CMS website and used for submission
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False
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Interest rates that apply to the Prompt Payment Interest Rate can be located on the Treasury’s Financial Management Service page
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True
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Medicare claims that require further investigation before being processed are referred to as “other” claims
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True
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A diagnosis should never be submitted without supporting documentation in the medical record
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True
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Claims fo dates of services in two different years may be submitted on the same claim form
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False
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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
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True
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Proofreading claims before submission can prevent denials and delay of claim processing
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True
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when submitting supplemental documentation for processing of a claim, the patient’s name and date of service need only be on the form of a two-sided document
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False
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handwriting is permitted on optically scanned paper claims
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False
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use the abbreviation “DNA” when information is not applicable
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False