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.

question

NUCC

answer

National Uniform Claim Committee

question

DDE

answer

direct data entry

question

CLIA

answer

Clinical Laboratory Improvement Amendments

question

EIN

answer

employer identification number

question

EMC

answer

electronic media claims

question

EPSDT

answer

early and periodic screening, diagnosis, and treatment

question

FECA

answer

Federal Employee's Compensation Act

question

NPI

answer

national provider identifier

question

LMP

answer

date of current illness, injury, or pregnancy

question

POS

answer

place of service code

question

PMP

answer

practice management program

question

PCP

answer

primary care physician

question

IN

answer

item number

question

SOF

answer

signature on file

question

EMG

answer

emergency indicator

question

a ____________billing service sending a claim is likely to be the

answer

billing provider

question

a ____________is the additional data in printed or electronic format

answer

claim attachment

question

a_____________ code is an administrative code used to identity the type of health plan, such as a PPO

answer

claim filing indicator

question

a claim that does not report at least one diagnosis code will be

answer

denied

question

a _____________elemement is HIPAA mandated

answer

required

question

a_________ element is mandated by HIPAA for reporting under certain (not all) conditions

answer

situational

question

A________ code is a 10 digit number that stands for a physician's medical specialty

answer

taxonomy

question

according to the NUCC manual, up to ______________diagnosis pointers can be listed per service line

answer

4

question

an__individual relationship code indicates the patient's to the insured

answer

relationship

question

an individual relationship code in needed when the patient and the insured are not the

answer

same person

question

by far the most common method of claim transaction is to hire outside vendors to handle the task

answer

clearinghouses

question

the claims an important step that comes before claim transmittal

answer

checking

question

choosing \" \" in item number 6 indicates that the insured is the patient

answer

self

question

claim attachment, such as lab results or descharge notes, are sent wither in printed or __________format to support a claim

answer

electronic

question

claims that are acceptable for adjudication by payers are called

answer

clean claims

question

common errors in claim generation include

answer

invalid procedure code, missing birthday, invalid infor and imcomplete other payer info

question

correct medical code sets are those valid at the time the healthcare is

answer

provided

question

correct medical code sets for claims are those that are _______ when the service is provided

answer

valid

question

__________________involves using an internet based service into which employees key the standard data elements

answer

direct data entry

question

editing software programs called____________ check claims to permit error correction

answer

claim scrubbers

question

for__________ elements, the provider must supply the data on every claim

answer

required data

question

HIPAA requires electronic transmission of claims, except for practices that have less than ________ full-time or equivalent employees and ___________ send any kind of electronic healthcare transactions

answer

10 never

question

if a release of information is required, then the release on file must be

answer

current---signed within the last 12 months

question

if another physician sent the patient, they need to be identified as the __________physician

answer

referring or ordering physician

question

in the direct transmission approach, providers and payers___________directly without using a clearinghouse

answer

exchange transactions

question

it may be necessary to identify________different types of providers

answer

4

question

item number______records the insurance identification number that appears on the insurance card of the person who holds the policy, who may or may not be the patient

answer

1-A

question

item number_______is used to enter the physician's or supplier's social security number or employer identification number(EIN)

answer

25

question

________,________________,and ____________ claims all require additional data elements

answer

medicare, EPSD, medicaid, and workman's comp disability

question

memorization is not required of medical insurance specialists in completing claims, but _____ and ___________ are

answer

good thinking and organization

question

on a HIPAA claim, _____is assigned to a particular service being reported

answer

line item control number

question

___________codes, describe the location where the service is provided

answer

place of service

question

POS code__________is used to indicate a procedure occured in an outpatient hospital

answer

22

question

POS code_______is used to indicate a procedure occured in a skilled nursing facility

answer

31

question

section 24 of the CMS-1500 records service line information, wheich contains the _____________

answer

procedures performed for the patient

question

the _______ is the Health Care Claim: professional

answer

837-P

question

the__________allows for a four-line address line for the payer

answer

carrier block

question

the carrier block is located on the upper right of

answer

CMS-1500

question

the claim filing indicator code_______is used to indicate a self-pay patient

answer

09

question

the health plan receiving a HIPAA claim is the___________payer

answer

destination

question

the HIPAA 837 claim does not require some data elements, including________________________________

answer

physician signature, balance due, marital status, or gender

question

the HIPAA 837 permits up to ___________diagnosis codes to be reported

answer

12

question

the HIPAA transaction for electronic claims generated by hopsitals is called the

answer

847-01

question

the HIPAA transaction for electronic claims generated by physicians is called the

answer

837-P

question

the HIPAA mandated electronic transaction for claims is the _______________or equivalent encounter information, and is usually called the \"837 claim\" or the \"HIPAA claim\"

answer

HIPAA X 12837 Health Care Claim

question

the items in the patient information section of the CMS_1500 identify_____________________

answer

patient, insured, health plan, and other case data and release information

question

the National Uniform Claim Committee (NUCC) determines the content of both_____________ and CMS-1500 claims

answer

HIPAA 837

question

the physician who actually provided the service is the _______

answer

rendering provider

question

the process of direct data entry loads claims directly into the ______________

answer

health plan's computer

question

the provider who provides the procedure on a claim OTHER than the pay-to-provider is called the_____________

answer

rendering provider

question

the responsible party is the ______________ other than the subscriber or patient who has financial responsibilty for a bill

answer

entity or person

question

the type of insurance, the patient's relationship to the insured, and the patient's or authorized person's___________ are all pieces of information included in the patient information section of the CMS-1500

answer

signature

question

there are three major methods of transmitting claims electronically; ___________, _____________. and ____________

answer

direct transmission, clearinghouses, or direct data entry

question

under HIPAA, as of 2012, EDI transactions must move to the______________version

answer

5010

question

under HIPAA, failure to transmit required data elements can cause a claim to be ________________by the payer

answer

rejected

question

under HIPAA, payers may not require providers to make changes or additions to the content of the HIPAA 837 claim; further, they cannot refuse to_______________________

answer

accept standard transactions, or delay payment of any proper HIPAA transaction, including claims

question

users of the CMS-1500 should check the_____________website for updated instructions

answer

NUCC

question

when nonspecific procedure codes such as________________CPT codes are used, the claim must contain service-line level description of the work done or the drug/dosage

answer

unlisted

question

HIPAA X12 837 HEALTH CARE CLAIM : PROFESSIONAL (837P)

answer

Form used to send a claim for physicain services to primary and secondary payers

question

CMS-1500

answer

Paper claim for physician services

question

CMS-1510*

answer

The new version

question

National Uniform Claim Commitee (NUCC)

answer

Organization responsible for claim content

question

CMS-1500 (08/05)

answer

Current paper claim approved by the NUCC

question

5010 Verison

answer

New format for EDI transactions

question

Carrier Block

answer

Data entry area in the upper right portion of the CMS-1500

question

Condition Code

answer

Two- digit numeric or alphanumeric code used to report a special condition or unique circumstance

question

Qualifier

answer

Two-digit code for a type of provider identification number other than the NPI

question

Billing Provider

answer

Provider of health services reported on a claim

question

Pay-To-Provider

answer

Entity that will receive payment for a claim

question

Rendering Provider

answer

Health care professional who provides health services reported on a claim

question

Other ID Number

answer

Additional provider identification number

question

Outside Laboratory

answer

Purchased laboratory services

question

Service Line Information

answer

Information about services being reported

question

Place of Sevice Code (POS)

answer

Administrative code indicating where medical services were provided

question

Administrative Code Set

answer

Required codes for various data elements

question

Taxonomy Code

answer

Administrative code set used to report a physician's specialty

question

Data Elements

answer

Smallest unit of information in a HIPAA transaction

question

Required Data Element*

answer

Information that must be supplied on an electronic claim

question

Situational Data Element*

answer

Information that must be on a claim in conjunction with certain other data elements

question

Responsible Party

answer

Other person or entity who will pay a patients charges

question

Claim Filing Indicator Code

answer

Administrative code that identifies the type of health plan

question

Individual Relationship Code

answer

Administrative code specifying the patients relationship to the subscriber

question

Destination Payer

answer

Health plan receiving a HIPAA claim

question

Claim Control Number

answer

Unique number assigned to a claim by sender

question

Claim Frequency Code (Claim Submission Reason Code)

answer

Administrative code that identifies the claim as original replacement, or void/ cancel action

question

Clean Claim

answer

Claim accepted by a health plan for adjudication

question

Line Item Control Number

answer

Unique number assigned to each service line item reported

question

Claim Attachment

answer

Documentation a provider sends a payer to support a claim

question

HIPAA X12 276/277 Health Care Claim Status Inquiry/Response

answer

Electronic format used to ask payers about claims

question

Claim Scrubber

answer

Software that checks claims to permit error correction

MEDICAL INSURANCE CHAPTER 7

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards