Medical Insurance – Chapter 13 – Flashcards
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A Medicare Redetermination Notice explains:
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Medicare's unfavorable response to a request for redetermination
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In general, how many levels are there when pursuing an appeal?
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three
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What kind of code appears on payers' electronic reports on the progress of transmitted claims in their adjudication process?
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claim status category codes
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How many steps are there in the Medicare appeal process?
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five
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Which of these HIPAA transactions is used by medical offices to ask payers about the status of submitted claims?
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276
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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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A medical practice may choose to ____________ a rejected or partially paid claim.
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either appeal or resubmit
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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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Claim adjustment reason codes are used by payers to explain entries in:
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RAs
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The __________ verifies the medical necessity of providers' reported procedures.
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claims examiner
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Prompt-pay laws govern:
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insurance carriers' payments of providers' claims.
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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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What will a payer do when a claim is submitted with outdated codes?
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Payers may deny a claim when outdated procedure codes are used.
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EFT is the abbreviation for:
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electronic funds transfer
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The first step in the Medicare appeals process is
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redetermination
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During the adjudication process, if there are problems during the automated review, the claim is pulled for
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development
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When a claim is pulled by a payer for a manual review, the provider may be asked to submit
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clinical documentation
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RA is the abbreviation for:
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remittance advice
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Who follow up on claims that are not processed within the specified claim turnaround time for the payer?
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Medical insurance specialists
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The term ______________ during claim adjudication means that the payer needs more information to process the claim.
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development
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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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What do MOA remark codes explain?
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adjustments to claims paid on a RA
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If the provider has not accepted assignment, the payer sends the payment to:
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the patient
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A payer's decision regarding whether to pay, deny, or partially pay a claim is called
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determination
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What is the correct order for the basic steps of a payer's adjudication process?
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initial processing, automated review, manual review, determination, and payment.
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The payer's processing of claims is called:
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adjudication
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What is done by a payer to determine the appropriateness of medical services?
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utilization review
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A payer's automated claim edits may result in claim denial because of
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lack of required preauthorization, medical necessity, or eligibility for a reported service
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Medical situations in which a patient receives extensive care from two or more providers on the same date of service are called
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concurrent care
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A payer's initial claim review may reject a claim due to
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an invalid policy number
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These codes might payers use to explain a determination:
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remittance advice remark code, claim adjustment reason code, and claim adjustment group code
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The payer sends the medical practice:
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a RA that covers a batch of processed claims
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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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A claim that is removed from a payer's automated processing system is sent for
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manual review
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Funds that are electronically transferred from a payer are directly deposited in the:
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practice's bank account
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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 list of claims transmitted and how long they have been in process with the payer is shown in the
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insurance aging report
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The first step the medical billing specialist should check when reviewing RAs is to:
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match up claims with the RA using the unique claim control number
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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 claim turnaround time is stated:
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in payers' policy manuals or contracts
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What does the abbreviation COB stand for?
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Coordination of benefits
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A medical review program is established by a(n):
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third-party payer
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A payer may _________ a procedure which it determines was not medically necessary at the level reported.
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downcode
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Which of these HIPAA transactions is sent by a payer to explain a claim payment?
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835
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Are improper or excessive payments resulting from billing errors for which the provider owes refunds to the payer.
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overpayments
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Medical billing programs that automatically records payments in the correct accounts.
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Autoposting
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What may result from a lack of clear, correct linkage between the diagnosis and the procedure?
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medical necessity denial
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The abbreviation MSP stands for:
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Medicare Secondary Payer
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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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What is the claim status when the payer is developing the claim?
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Suspended
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If a medical practice believes that it has been treated unfairly by an insurance company, it has the right to file a ____________ with the state insurance commission.
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grievance
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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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The process of determining whether to pay, reject, deny, or partially pay claims.
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Adjudication
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The payer's decision regarding payment.
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determination
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What does "reconciliation" mean?
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double-check that totals are accurate and consistent
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The process of verifying that the totals on the RA are mathematically correct.
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reconciliation
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The claimant
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patient or provider who appeals a claim
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RAs generally have information on any:
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errors, adjustments, and denials on the listed 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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Is the person or entity who seeks to receive benefits via an appeal.
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claimant
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An aging report groups unpaid claims or bills according to:
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the length of time that they remain due
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Which of these HIPAA transactions is sent by a payer to answer a question about a submitted claim?
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277
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Remittance advice remark codes are maintained by ________ but can be used by all payers.
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CMS
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The abbreviation MRN stands for:
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Medicare Redetermination Notice
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Concurrent care
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Is provided to a patient on the same date at the same place of service by two or more physicians
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If Medicare is the secondary payer, the claim must be submitted using the:
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HIPAA 837
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Concurrent care?
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a case in which a patient is attended by two physicians, such as a cardiologist and a thoracic surgeon, during surgery
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An insurance aging report lists:
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unpaid claims
