Medical Insurance- Chapter 13 – Flashcards
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A __________occurs when a procedure and a diagnosis are not correctly linked, in the opinion of the payer.
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Medical Necessity Denial
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_____________ is the process of determining whether to pay, reject, deny, or partially pay claims.
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Adjudication
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Minor errors found by the practice on transmitted claims require which of the following:
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corrections by asking the payer to reopen the claim and make the changes
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The claim turnaround time is the period between:
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the date of claim transmission and receipt of payment
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An insurance aging report lists
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Unpaid claims
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Prompt-pay laws govern
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insurance carriers' payments of providers' claims
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The payer's RA shows:
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both the amount the provider is allowed and the amount patient pays
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RA is the abbreviation for:
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remittance advice
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When a payer's RA is received, the medical insurance specialist
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checks that the amount paid matches the expected payments
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What does "reconciliation" mean?
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to double-check that totals are accurate and consistent
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______________ is a feature of some medical billing programs that automatically records payments in the correct accounts.
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Autoposting
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When is an appeal sent to third-party payers?
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after a claim is rejected or paid at less than the expected amount
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A medical practice may choose to ____________ a rejected or partially paid claim
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either resubmit or appeal
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The abbreviation MRN stands for:
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Medicare Redetermination Notice
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What does the abbreviation COB stand for?
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Coordination of benefits
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The abbreviation MSP stands for
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Medicare Secondary Payer
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A payer's determination means it is going to:
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pay, deny, or partially pay the claim
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A payer's automated claim edits may result in claim denial because of
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lack of eligibility for a reported service, lack of medical necessity, lack of required preauthorization, any of these
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On an aging report, which category describes a current invoice?
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0-30 days
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If a provider has accepted assignment, the payer sends the RA to:
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the provider
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Which of these codes might payers use to explain a determination?
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claim adjustment group code, claim adjustment reason code, remittance advice remark code, all of these answers are correc
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The advantage(s) of EFT for practices is(are)
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funds are available immediately and the transfer is less costly than check deposits.
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The Medicare Secondary Payer program coordinates the benefits for patients who have both Medicare and
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any other insurance coverage.
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If a Medicare beneficiary receives treatment for an accident-related claim, the Medicare plan is Multiple Choice
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secondary
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If a Medicare beneficiary is covered by a spouse's employer group health plan, the Medicare plan is
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secondary
