Claims Process

Billing for services not provided is an example of ___.  A. incentives  b. pre-planning  c. fraud  d.  abuse

Claims for services deemed not medically necessary by insurance plans or programs are examples of ____.  A . abuse  b. hardship waivers  c.  improper delegation  d.  fraud

For the physician involved,  Medicare or Medicaid program- related crimes result in ____.  A. insurance cancellation  b.  embezzlement charges  c.  higher malpractice insurance  premiums  d. exclusion from program participation

Misconduct that occurs within a physician’s field of expertise and results in injury or loss to the recipient of services is called _____.  A. liability b. slander  c. malpractice  d. negligence

Before performing surgery, what must the physician obtain from the patient?  A.  informed consent  b. diagnosis and prognosis  c. admission of fault  d. second opinion

If a patient does not follow instructions, does not take recommended medications, and fails to return for an appointment, the physician may ___.  A. prescribe medication for mental issues b. waive an arbitration agreement c. terminate further care of the patient d.  recommend further tests

A form sent to the insurance company to find out the maximum dollar amount that will be paid for a procedure is called an insurance _____.  A. certification form b. preauthorization form  c. precertification form  d. predetermination form

A government program that provides medical services for dependents of active military personnel is known as ____.  A. Medicare  b. Medicaid c. TRICARE  d. CHAMPVA

An organization that provides a wide range of services for a specified group at a fixed periodic payment is called a(n) _____.  A. PMO  b. HMO  c. PPO  d. PPS

In California, the Medicaid program is called ___.  A. Calimed  b. HMO  c. Medicare  d. Medi-Cal

A program that insures a person against on-the-job injury or illness is called ___.  A. state disability  b.  workers’ compensation c. workmen’s insurance  d. prepaid health

One of the first steps in processing an insurance claim is to _____.  A. obtain a Release of Information Statement  b. evaluate the laboratory results  c. post payment to the day sheet  d.  take a comprehensive history

A convenient arrangement for following up on the progress of paper insurance claims is to use a ____.  A. calendar  b. rolodex  c. tickler file  d. ledger

Third party payers require all the following information EXCEPT _____. A . triplicate copies of invoices b. diagnoses using ICD-9-CM codes c. DOS d. POS

Careful and thorough recording of information at the time of the initial office visit ____.  A. takes too long  b.  is always done by insurance specialist  c. enables one to handle insurance claims promptly  d.  is done only when the patient is scheduled for surgery

Obtaining all the names of insurance companies from patients is important for ____.  A. notifying next of kin  b. purging the alpha file  c. making future appointments  d.  coordinating benefits

Another name for the release of information form is the _____.  A. assignment of benefits  b.  requisition form  c.  consent form  d. spreadsheet

The number of views, part of the body, and type of view are necessary pieces of information for itemizing ____.  A. level of E/M service b. x-rays c. location of a tumor d. laboratory work

If a claim is filed after submission time limit for the carrier, the payment is usually ____.  A.  processed  b.  guaranteed c. denied d. suspended

Incorrect payments from an insurance company should be ___.  A. appealed  b.  accepted  c.  forwarded to the patient  d .deposited

Assignment means which of the following:  a. contracting with an insurance company  b. accepting what the insurance company pays for a claim c. requesting that the patient’s health benefit payment be sent to the doctor  d. having a specialist assigned to the patient

The amount that a physician normally or usually charges the majority of his or her patients is the _____.  A .usual and customary provider fee  b. RUV  c. RBRVS  d. UCR

When coding some procedures and services it is sometimes necessary to add a 2 digit modifier to _____.  A. indicate usual charges  b. provide more information for the insurance company  c. give a more accurate description  d.  all choices are correct

Random audits of medical records by insurance carriers are used to ____.  A. catch errors by insurance companies  b. monitor coding accuracy  c. assess physician dictation timeliness  d. revise CPT codes

A patient was seen in February. He has not met his annual deductible. What should the billing specialist do? A. Delay claim submission until the deductible has been met  b. Don’t submit the claim; office will collect the full charges, including deductible.  C. Submit the claim in December because the deductible will be met by then  d. Submit the claim within the applicable timely filing limits

A correctly completed claim submitted within the policy time limit is termed a ____.  A. paper claim b.  paid claim  c. legal claim d. clean claim

An EOB document may include all of the following EXCEPT ____.  A deductible  b. patient name  c.  allowed amounts  d. coding updates

Claims paid with no errors are considered ____. A. closed  b. pending  c. filed  d. suspended

A group of electronic claims submitted from one facility is termed a _____.  A. bunch b. batch c. cluster  d. bundle

From beginning to end, an electronic claim versus a paper claim requires _____.  A. fewer steps  b. more steps  c. signature stamps  d.  documents be sent

A third party entity that receives, separates, and transmits claims to the appropriate payer is called a(n) _____.  A. carrier  b. insurance specialist  c.  clearinghouse  d. national network

Medicaid policy allows for coverage and payment of all services that are ____.  A. billed by a physician  b.  medically necessary  c. viewed as appropriate by the physician  d.  less than $100

A plastic card containing information regarding a patient’s insurance, history and eligibility is called a ____.  A.  disk b. record  c. debit card  d. smart card

When a physician modify, change, or add an addendum to a medical record?  A.  only after a claim is submitted b. only before a claim is submitted  c.  Never  d. When an omission or error comes to his or her attention

Large medical practices generally submit electronic claims ____.  A. daily b. hourly  c. weekly  d. monthly

A digital fax claim is a claim that arrives at the insurance carrier via fax machine but is ___.  A. printed on paper  b.  never printed on paper  c. duplicated and verified  d. monitored by phone

In order to receive the carrier’s fax back verification, the physician’s office ____. A. runs a test phase  b.  follows a schedule  c. fax must be turned on  d. staff must be present

Which of the following is NOT recommended on faxed claims?  A. Dark, distinct print  b.  Font size of 10-14 points  c. Handwritten information  d. CMS-1500 forms

Submissions to the insurance commissioner should be handled ___.  A. electronically  b. by telephone c. in writing  d.  by the patient

If an insurance carrier sends payment directly to the patient even though the physician has been assigned the benefits, the ____. A. carrier must pay the physician within 2 to 3 weeks b. payment is not recoverable  c. patient will pay the physician  d. physician will revoke the assignment of benefits form

The following are types of problem claims EXCEPT ____.  A. partial payment  b. clean claims  c. delinquent claims d. suspended claims

The following are common reasons for denial of claims EXCEPT ____. A. deleted codes  b. when gender does not match service  c. correct dates of service  d.  transposed numbers

If a claim is denied for lack of medical necessity and the physician feels the service was medically necessary, the physician should ____.  A. contact the commissioner  b. write a letter of appeal  c. resubmit the claim d. write off the amount of the claim

An inquiry made to locate the status of an insurance claim is called a ____. A. follow-up  b. tracer  c.  review  d. tracker

If an appeal for a legitimate claim is unsuccessful, the physician may request a ____.  A. different tracer  b. refund  c. new carrier arrangement  d.  peer review

It is important for TRICARE  patient to always ___.  A. present a military ID  b. submit the claim on-line c. register with Social Services  d. enroll with DEERS

If a nonmember physician treats an HMO patient, the services are termed ____.  A. provisional  b.  approved  c. out of plan d. improper

Which of the following practices would NOT be noted by utilization review? A. Churning  b. Turfing  c. Excessive overtime  d. Buffing

Capitation refers to a ____.  A. type of payment agreement where the physician is paid per person whether seen or not  b. type of posting done manually in the physician’s office  c. fee for service agreement where a dollar amount is set for each service or procedure  d. tax paid by the physician to the Internal Revenue Service

An indemnity benefit contract ____.  A. offers physician participation b. makes no promise to cover a full fee  c.  is a service contract  d. is offered through Medicare

Second opinion programs ___. A . refer data to clearinghouses  b. are billed electronically  c. benefit referring physicians d. reduce the incidence of surgery

Which of the following is an ERISA benefit plan? A. an HMO through Blue Cross provided by Walmart to an employee of Walmart  b.  an Hmo through Aetna provided by the Catholic Church to a priest  c. A PPO through United Healthcare provided by the city of Dallas to a city employee  d.  a POS provided through a Medicare Part C plan

Each state designs its own Medicaid program within ____.  A. local guidelines  b. federal guidelines  c.  international guidelines  d. AMA guidelines

All but which of the following may be covered by Medicaid? A. 65 year old business executives b. Patients who cannot see  c. Patients with disabilities  d. 65 year old patients

In the Medicaid program, which one of the following groups is NOT usually considered categorically needy?  A. QMBs  b. AFDC –related groups  c. SSI cash recipients d. Military dependents

Which of the following is NOT covered by Medicaid ?  a. Birth control  b. Cosmetic surgery c. X-rays d. Immunizations

Prior approval for certain services in the Medicaid program is necessary EXCEPT for ____.  A. transportation b. a true emergency  c.  hearing aids  d.  prosthetic devices

All but which of the following might be covered by Medicaid? A. Inpatient care for a digestive disorder  b. Hemodialysis for a kidney patient  c. Surgery (hysterectomy) for the dysfunctional uterine bleeding d. Contact lens to change the color of the eyes

If a patient requires care while out of state, most states offer Medicaid ____.  A. training b. education c. reciprocity d. refunds

If a Medicaid bill is submitted after the time limit it will most likely be ____.  A. rejected b .reviewed c. paid d. ignored

Medicaid eligibility for participants should be verified every ___. A. month b. three months  c.  six months  d. year

If a person eligible for Medicaid has other insurance coverage, Medicaid is always the ____. A. first insurance billed  b. responsible third party liability carrier  c. primary carrier  d.  secondary carrier

Medicare is a federal health insurance program for the following categories of people EXCEPT ___. A . people 65 years or older  b. preschool children with no permanent disabilities  c. blind individuals  d.  disabled widows

For Medicare inpatient services, a benefit period begins the ___.  A. day a patient enters the hospital b. first day the physician sees the patient in the office for the illness or injury  c.  3rd day of a hospital stay  d. first day home from the hospital

A patient might submit his own Medicare claim when ____.  A. the hospital is in a rural location b. the time limit has passed c. purchasing medical equipment d the physician is too busy

When an illiterate patient cannot sign a Medicare form, ____.  A. s/he should be referred to a literacy program  b. a supervisor should be notified  c. a witness should sign the form  d. care is denied

To be eligible for Medicare, an alien resident must have lived in the U.S. for ____.  A. 5 consecutive years  b. 3 consecutive years  c. 1 year  d. 10 years

If the Medicare beneficiaries have memory impairment, they have a legal right to ____ .a hearing aids b. appoint a representative c. private hospital rooms  d. audit their claims

A physician may be penalized by Medicare for ____.  A. billing for laboratory services  b. submitting a late claim c.  billing for services not provided  d. billing inpatient services

When a patient is scheduled to receive a service that is not covered by Medicare, it is recommended to ____.  A. advise the patient prior and obtain an ABN when needed  b. confer with the physician prior to providing the service  c. submit a claim as usual  d. appoint a representative

Mandated by HIPAA and implemented in May 2005, the standard unique identifier that all health care providers will be required to use when filing and processing health care claims is the ____.  A. UPIN   b. NPI  c. PIN  d. SUI

When a patient is placed in custodial care in a nursing home, Medicare will ____.  A. pay 80%  b.  pay 50%  c.  25% d.  pay nothing

Medigap policies ____.  A. supplement the traditional Medicare policy  b. supplement the Medicaid program  c. supplement private insurance  d. are regulated and offered by individual states

It is important for the insurance billing specialist to determine whether a patient’s Medicare coverage is primary or ____.  A. tertiary  b. supplemental  c.  MSP  d.  indemnity

Some HMO’s provide Medicare patients with ____.  A. eyeglasses  b. cosmetic surgery  c.  therapeutic massage  d. personal trainers

If medical services are covered under an auto insurance policy, the ____.  A. auto insurance is secondary  b. auto insurance is primary  c.  patient files the claim  d. auto insurance is billed after the primary insurance pays

In a case of auto insurance coverage, claims for Medicare benefits may be submitted ____.  A. only after denial by the primary insurer  b. only after the patient has recovered  c.  within 2 years of the auto accident  d. at any time

Receiving Medicare payment for a patient who has died is _____.  A. rare  b.  impossible  c.  possible  d.  unusual

Medicare mandated prepayment screens are intended to ___.  A. assist physicians  b. facilitate the filing of claims  c. prevent unnecessary services  d. monitor patient activity

An overpayment check from Medicare should be _____.  A. returned to Medicare  b. filed in the physician’s office  c. held until action is specified by Medicare  d. deposited and reported to Medicare

TRICARE Standard is similar to a _____.  A. HMO plan  b. PPO plan  c. fee- for- service plan d. senior Medicare plan

All of the following may receive benefits under CHAMPVA EXCEPT ____.  A. spouses of disabled veterans  b. active duty military dependents  c. children of disabled veterans  d. surviving spouse of a veteran

For participating physician services, what portion of the patient’s expenses does Medicare pay?  A. 20% of the Medicare allowed amount  b. 20% of the physician’s billed amount  c. 80% of the physician’s billed amount  d. 80% of the Medicare allowed amount

If an army or navy hospital cannot provide a TRICARE patient with a needed service, ____.  A. the patient must forego that service  b. a congressman is notified c. the ombudsman may be contacted  d. the patient may go to a civilian hospital

The following healthcare provider may treat a TRICARE patient EXCEPT which one? a. M.D.  b. Doctor of homeopathy  c. Audiologist  d. Physical therapist

DEERS is a ____.  A. data base for military personnel and family  b.  conservation program for physicians  c. type of claims processing procedure  d. payment notification system

TRICARE Prime co-payments are collected ___. A. monthly b. at the time services are rendered c. at the time the patient registers  d. at the time of claim submission

Some very large employers have fought high medical costs of employee accidents by ____.  A. lobbying for legislation  b. self-insuring employees c. promoting workers’ compensation reform  d. using mediators instead of lawyers

The minimum number of employees required for a company in order for state workers’ compensation to be effective is _____.  A . 1 to 5  b. 2 to 6 c. 3 to 7 d. 5 to 10

Types of compensation benefits for injuries on the job include the following EXCEPT ____.  A medical treatment b. temporary disability payments  c. legal fees  d. survivors’ benefits

A minor injury on the job in which the patient is seen by a doctor but is able to continue working is a ____.  A. non-disability claim  b. temporary disability claim c. permanent disability claim  d. retroactive claim

Medicaid is always the ____.  A. primary insurance  b .secondary insurance c. payer of last resort  d. only claim submitted

Vocational rehabilitation may include the following EXCEPT ____.  A. severance benefits  b. physical therapy  c. job placement  d. retraining

If an employee’s injury prevents the return to a previous occupation, s/he may ____. A. receive SSI  b. receive unemployment  c. be trained for another career  d.  receive permanent total disability

A permanent disability rating depends on the following EXCEPT ____.  A. level of income  b. occupation at the time of injury  c.  age of the injured  d. severity  of the injury

In a permanent disability claim, an agreement between the injured party and the insurance company is called a ____.  A.  P &S agreement  b. permanent disclosure  c. disability petition  d.  compromise and release

Final determination of issues concerning settlement of an industrial accident are called _____. A. adjudication b. closure  c. petition and appeal  d. case completion

Surveillance videotapes obtained to disqualify a person from receiving permanent disability are termed ____.  A. silence films b. sub rosa films  c. clandestine films  d. detective films

Which of the following is NOT a sign of fraudulent workers’ compensation claims?  A. Missing the first physician appointment  b. Vague and dramatic complaints  c. Complaining of pain  d. Changing physicians frequently  

A person who makes a fraudulent claim for workers’ compensation is guilty of ____.  A. willful injury  b.  a misdemeanor  c. misrepresentation  d. a felony

An employer could be guilty of workers’ compensation fraud if he or she does any of the following EXCEPT ____.  A. misrepresents the annual payroll  b. gives a false address  c. reports an accurate number of workers  d. falsely classifies the job duties of workers

The office whose purpose is to protect employees against on the job health and safety hazards is ___.  A. OSHA b. AMA c. CLIA d. EDTA

Which of the following are not covered by occupational safety laws?  A. Nonprofit institutions b. Farmers’ immediate family members  c. Religious hospitals  d. Light industry workers

Workers who come in contact with the HIV virus have a right for the workplace to supply them with ____.  A. a leave of absence  b. a different job  c.  information regarding precautions  d. vaccinations

An OSHA inspector may visit a medical office ____.  A. every year  b.  by invitation  c.  unannounced  d. accompanied by law enforcement officials

A proceeding in which an attorney asks a witness questions but not in open court is termed a (n)  ____.  A. deposition b. testimony  c.  inquisition d. interrogation

If a physician assigns a delinquent account to a collection agency, the physician may ____. A . collect full payment directly from the patient  b.  lose a percentage of the charge c. lose the entire fee d. violate collection laws

Copies of a lien in a workers’ compensation case should be sent to the following EXCEPT ____. A. patient’s employer b. insurance carrier  c. state insurance commissioner  d. appeals board

The Subsequent Injury Fund was established to meet problems which arise when a ____. A. previously injured person is injured again at work  b. rehabilitated person returns to work  c. military person is injured on the job  d. claim is filed later than the time limit

Medical records for industrial injuries should be set up separately from private medical records because _____.  A. paperwork is reduced  b. there are separate disclosure laws for each  c. colored files are easier to view  d. it will save space

Physician narrative letters, which support claims regarding accidents, should include the following EXCEPT _____. A . complete medical findings b. patient’s present complaints  c. history of the accident  d. a police report

 If another condition not related to the industrial accident or injury is discovered during the course of a treatment for a workers’ compensation case, _____.  A. it is included in the workers’ compensation case  b. the patient is financially responsible  c.  a second claim is filed with workers’ compensation d. the employer is responsible

The time frame between the beginning of the disability to receiving the first payment of disability benefits is the ____.  A. waiting period  b. eligibility period  c. benefit period  d. exclusion

Benefits paid to the insured while disabled are called ____.  A. premiums  b. deductible  c. indemnity d. provisional

If the insured has a work-related impairment that is expected to continue for his or her lifetime, he or she is considered _____. A. temporarily disabled  b. totally disabled  c. rehabilitated d. permanently disabled

 Benefits from disability insurance are not taxable if the premiums are paid by the _____.  A .individual  b. state c. federal government  d. professional association

In some policies, a provision for death resulting from an unexpected and unforeseeable accident is called _____.  A. waiver of premium  b.  dismemberment  c. double indemnity  d. total indemnity

Which of the following is NOT an example of a typical exclusion in an insurance policy?  A. attempted suicide  b. injury due to acts of war  c. condition arising while legally intoxicated  d. congestive heart failure

Group disability income insurance commonly covers _____.  A. payments for short term conditions  b. medical expenses due to HIV  c. self- inflicted injury  d. retirement benefits

Which of the following would probably NOT be covered by group disability insurance plans?  A. loss of income payments  b. long term disabilities  c. short term disabilities  d. medical expenses

Disability payments provided to needy people with limited income and few resources are provided by ____. A Medicare  b. workers’ compensation c. SSI  d. Medicaid

Special rules allowing disabled people to work while receiving government benefits are called ___ .a internships  b. work incentives  c. scholarships  d. shadowing

Which of the following would probably not be covered by VA benefits?  A. Non-prescription drugs  b. Travel expenses to a VA hospital c. Agent Orange exposure d. Alcohol outpatient care

Reasons for denial of a non-work related disability claim could include ____.  A. inadequate medical information  b. subjective symptoms  c. dates of disability  d.inclusion of photocopies of lab tests

All of the following are options for careers in the billing and coding field EXCEPT ____.  A. CT technician  b. claims assistance professional  c. electronic claims processor  d. insurance billing specialist

Patients who leave the hospital without notifying medical personnel or against the advice of medical staff are given the discharge status of ____. A. AWOL  b. AMA  c. DOA  d. ambulatory patient

An organization, which provides pain relief and symptom management to the terminally ill is called ____.  A. a domiciliary  b. hospice  c. a caravansary  d. home support agency

Not doing something that a reasonable person would do under ordinary circumstances or doing something that a reasonable person would not do is called ____.  A. negligence  b. willfulness c. irresponsibility  d. mental illness

Diagnostic tests done 1 to 3 days before a patient is admitted to a hospital are called ____.  A. post-admission testing  b.  admission preliminaries  c. pre-admission testing d. outpatient work

Physician liability in certain cases for wrongful acts of assistants and employees is called ____. A. restrictive liability b. respondeat superior  c. master privilege  d. status quo

Services provided by specialists such as neurosurgeons and intensive care units are often viewed as ____. A. tertiary care  b. binary care  c. skilled care  d. primary care

A process  by which an insurance company attempts to recover losses from a third party who caused a loss is called ___.  A. review of damage b. third party adjudication  c. third party subrogation  d. medical service order

A primary care physician who controls patient access to specialists is called a(n) ____.  A. gatekeeper  b. ancillary physician c. primary staff d. risk incentive promoter

Kidney donor coverage includes ____.  A. preoperative testing  b. surgery  c. postoperative services  d. all answers are correct

All payments for medical expenses incurred by a kidney donor are made directly to the ____.  a. Health care providers  b. kidney donor c. kidney recipient d. physician in charge

An ____ must be obtained for all services that are not medical necessary according to Local Coverage Determinations and/ or National Coverage Determinations, with just a few exceptions.  A. Advance Directive  b. Advance Beneficiary Notice  c. Ancillary Services Permit  d. Ancillary Benefit Directive