Insurance Study Guide Chapter 7 – Flashcards
99 test answers
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What can users do to stay up-to-date with the CMS-1500?
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Check the NUCC website for updated instructions
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Which describes the meaning of transaction "837P"?
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Professional
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Which of the following benefits do medical insurance specialists gain by becoming familiar with the information most often required on claims their practice prepares?
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Ability to respond to payers' questions
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Why has sending paper claims become less common?
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The increased use of information technology
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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.
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Ten
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Under HIPAA, payers may not:
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Refuse to accept the standard transactions
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Name the current paper claim approved by the NUCC.
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CMS-1500 (08/05)
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HIPAA EDI transactions are sent via:
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5010 version
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Where is the carrier block located on the CMS-1500?
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Upper right
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Which of the following pieces of information are included in the patient information section of the CMS-1500?
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Patient's relationship to insured
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Name the function of the carrier block.
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It allows for a four-line address for the payer
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Identify the information included in blocks 1 through 13 of the CMS-1500.
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Information about the patient and the patient's insurance coverage
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What item is not included in the patient information section of the CMS-1500?
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The diagnosis
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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.
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Item Number 9
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Name the condition code you would apply to an abortion performed due to social or economic reasons.
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AG
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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.
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Item Number 12
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Explain the purpose of Item Number 10A-10C on the CMS-1500.
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To determine liability for the condition
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How current must the signature on file have been obtained for the release of information to be permissable?
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Within twelve months
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What choice may be made in Item Number 6 to show that the insured is the patient?
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Self
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The insured's ID number is the:
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Identification number of the policy holder
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A billing service sending a claim is likely to be the:
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Billing provider
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Identify the person or organization that receives payment.
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The pay-to provider
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The provider who provides the procedure on a claim other than the pay-to provider is called the:
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Rendering provider
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How many different types of providers may need to be identified?
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Four
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If a patient was sent by another physician, that physician is known as the:
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Referring physician
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Examine the following entities and determine which may act as a billing provider.
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A clearinghouse, practice, and billing service
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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?
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The rendering provider
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The physician who actually provided the service is the:
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Rendering provider
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A legacy (non-NPI) ID number has two parts, the number itself as well as a(n):
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Qualifier
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Section 24 of the CMS-1500 records service line information, which contains the:
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Procedures performed for the patient
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Physicians identify their medical specialty by using:
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Taxonomy codes
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Which of the following codes could be used to indicate that a procedure took place in a medical office?
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Place of service codes
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What type of code may not be required by HIPAA, but if used, must be chosen from the NUCC list?
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Administrative codes
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What is recorded in Section 24 of CMS-1500?
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Procedures performed for a patient
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Determine where you would report a service that was performed by an outside laboratory on the CMS-1500
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Item Number 20
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Correct medical code sets are those that are:
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Valid at the time the service was performed
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Determine which of the following may be a qualifier.
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1B
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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.
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Item Number 19
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Name the qualifier used to indicate a provider's taxonomy number.
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ZZ
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Name the qualifier used to indicate a provider plan network identification number.
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N5
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Explain how a payer will respond to a claim that does not contain an ICD-9 (or -10)-CM code.
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The payer will deny the claim
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Discuss the purpose of the shading in the top portions for the six service lines in Section 24 of the CMS-1500 claim form.
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To allow for six lines of service
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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.
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Provide a special report
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How many diagnosis pointers can be listed per service line according to the NUCC manual?
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Four
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What type of signatures should usually be used in Item Number 31?
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No signature required; leave blank
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What information might be recorded in Item Number 25?
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The physician's or supplier's EIN or SSN
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Name the POS code used to indicate a procedure occurred in an outpatient hospital.
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22
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Name the POS code used to indicate a procedure occurred in a skilled nursing facility.
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31
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A data element that HIPAA always madates reporting is called a(n):
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Required data element
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A data element that HIPAA mandates reporting under certain conditions is called a(n):
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Situational data element
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Determine what was not required of PMP vendors when the HIPAA 837 electronic transaction was mandated.
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Providing updates at no additional cost
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Name the HIPAA transaction for electronic claims that was generated by physicians.
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837 P
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Name the HIPAA transaction for electronic claims that were generated by hospitals.
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847I
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What are the five sections on a claim?
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Provider, subscriber, payer, claim details, services
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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.
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NRUC
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Which of the following is a data element that is required on the HIPAA 837 claim?
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The billing provider name and telephone number
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Under HIPAA, what may happen if the required data elements are not transmitted?
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The payer may reject the claim
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What is the terminology used when the provider must supply the data element on every claim?
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Required data element
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Name the data element that is required for use on the HIPAA 837P in conjunction with CMS Item Number 30.
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This data element is "NOT USED"
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Explain the reason why the five levels of the HIPAA 837 are set up as a hierarchy.
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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.
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When the subscriber and the patient are the same person, what patient data is required on the HIPAA 837?
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The patient data is not required if the subscribed and the patient are the same
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When the patient and insured are not the same person, what type of code is required to indicate this fact?
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Individual relationship code
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Identify what is indicated by an individual relationship code.
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The patient's relationship to the insured
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On a HIPAA claim, which of the following is assigned to a particular service being reported?
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A line item control number
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On a HIPAA claim, determine which of the following is assigned to a claim by the sender.
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Claim control number and line item number
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What is sent as additional data to support a claim?
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Attachment
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Correct medical code sets for claims are those that are:
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Valid at the time the service is provided
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Correct administrative code sets for claims are those that are:
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Valid at the time the transaction is started
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The responsible party is held accountable for:
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The financial responsibility for a bill
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What does a claim filing indicator code identify?
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The type of health plan
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Identify the claim filing indicator code that is used to indicate a self-pay patient.
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09
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Identify the claim filing indicator code that is used to indicate the the health plan is Medicaid.
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MC
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What is the payer's responsibility sequence number for the payer of last resort?
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T
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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.
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Submit the claim with "Unknown" entered for the patient's address
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What entity is the destination payer?
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The health plan receiving a HIPAA claim
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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.
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7
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How many diagnosis codes may be reported on the HIPAA 837?
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Twelve
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How many of the diagnosis codes reported on the HIPAA 837 may be linked to each reported procedure?
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Four
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What information about an accident is not required to be reported on the HIPAA 837 claim?
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The name of the person who caused the accident
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Describe the circumstances under which the last-seen date is not required to be reported on the HIPAA 837 claim.
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A physician's services involving routine foot care
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When nonspecific procedure codes such as unlisted CPT codes are used, the claim must contain:
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Service-line level description of the work or drug/dosage
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In which format can claim attachments be sent?
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Electronic or paper format
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Which of the following payers usually do not require additional data elements?
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Fee for services claims
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Claims that are acceptable for adjudication by payers are called:
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Clean claims
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Identify the important step that immediately proceeds claim transmittal.
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Checking the claim
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Describe the reason for and the process of "dropping to paper."
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The practice prints and sends the CMS-1500 paper claim because the payer has not acknowledged receipt of it via electronic transmission
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Which one of these is not considered to be a common error in generating claims?
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Patient name
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When entering data for a claim, do NOT:
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Use hyphens in the telephone numbers, use prefixes in people's name, use a dash in zip code
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How many major methods are there for transmitting claims electronically?
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Three
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In which of these methods of transmitting claims do providers and payers exchange transactions directly without using a clearinghouse?
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Direct transmission to the payer
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In which of these methods of transmitting claims can employees key standards data elements using an Internet-based service?
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Direct data entry
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Choose the editing software programs sued to check claims for error correction.
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Claim scrubbers
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What is the most common method of claim transmission?
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Clearinghouse use
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Name the electronic format that practices use to ask payers about claims.
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HIPAA X12 276/277
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Using the process of DDE, claims are loaded directly into:
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The health plans' computers
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