Insurance Chapter 4: Prossessing An Insurance Claim

25 Questions  I  By Phliproc
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  • 1. 
    Which means that the paitent and or insured has authorized the payer to reimburse the provider directly?
    • A. 

      Accept assignment

    • B. 

      Assignment of benifits

    • C. 

      Coordination of benifits

    • D. 

      Medical necessity


  • 2. 
    Providers who o not accept assignment of Medicare benefits do not receive information included in the ______, which is sent to the patient.
    • A. 

      Electronic flat file

    • B. 

      Encounter form

    • C. 

      Ledger

    • D. 

      Medicare summary notice


  • 3. 
    The transmissions of claims data to payers or clearinghouses is called claims...
    • A. 

      Adjucation

    • B. 

      Assignment

    • C. 

      Processing

    • D. 

      Submission


  • 4. 
    Which facilitates processing of nonstandard claims data elements into standard data elements?
    • A. 

      Clearinghouse

    • B. 

      EHNAC

    • C. 

      Payer

    • D. 

      Provider


  • 5. 
    A series of fixed length records submitted to payers to build for health care services is an electronic
    • A. 

      Flat file format

    • B. 

      Funds transfer

    • C. 

      Remittance adice

    • D. 

      Source document


  • 6. 
    Which is considered a covered entity?
    • A. 

      EHNAC which accredits clearinghouses

    • B. 

      Private sector payers that process electronic claims

    • C. 

      Provider that submits paper based CMS-1500 claims

    • D. 

      Small self administered health plan that processes manual claims


  • 7. 
    A claim that is rejected because of an error or an omission is considered an  
    • A. 

      Clean claim

    • B. 

      Closed claim

    • C. 

      Delinquent claim

    • D. 

      Open claim


  • 8. 
    An electronic claim is submitted by using _________ as its transmission media.
    • A. 

      Facsimile machine

    • B. 

      Magnetic tape

    • C. 

      Scanning device

    • D. 

      Software that prints claims


  • 9. 
    Which supporting documentation is associated with submission of an insurance claim?
    • A. 

      Accounts recievable

    • B. 

      Claims attachment

    • C. 

      Common data file

    • D. 

      Electronic remittance advice


  • 10. 
    Which is a group health insurance policy provision that prevents multiple payers from reimbursing benefits by other policies?
    • A. 

      Accept assignment

    • B. 

      Assignment of benefits

    • C. 

      Coordination of benefits

    • D. 

      Pre-existing condition


  • 11. 
    The sorting of claims upon submission to collect and verify information about the patient and provider is called claims
    • A. 

      Adjucation

    • B. 

      Authorization

    • C. 

      Processing

    • D. 

      Submission


  • 12. 
    Which of the following steps would occur first?
    • A. 

      Clearing house converts electronic claims into electronic flat file format

    • B. 

      Clearinghouse verifies claims data and transmits to payers

    • C. 

      Health insurance specialist batches and submits claims to clearinghouse

    • D. 

      Health insurance specialist completes electronic or paper based claim


  • 13. 
    Comparing the claim to payer edits and the patients health plan benefits is part of claims...
    • A. 

      Adjucation

    • B. 

      Processing

    • C. 

      Submission

    • D. 

      Transmission


  • 14. 
    Which describes any procedure or service reported on a claim that is not included
    • A. 

      Medically unnecessary

    • B. 

      Non-covered benefit

    • C. 

      Pre-existing condition

    • D. 

      Unauthorized service


  • 15. 
    Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider?
    • A. 

      Common data file

    • B. 

      Encounter form

    • C. 

      Patient ledger

    • D. 

      Remittance advice


  • 16. 
    Which is the fixed amount patients receive each time they receive health care services?
    • A. 

      Coinsurance

    • B. 

      Copayment

    • C. 

      Deductable

    • D. 

      Insurance


  • 17. 
    Which of the following steps would occur first?
    • A. 

      Clearinghouse transmits claims data to payers

    • B. 

      Payer approves claim for payment

    • C. 

      Payer generates remittance advice

    • D. 

      Payer performs claims validation


  • 18. 
    Which must accept whatever a payer reimburses for procedures or services performed?
    • A. 

      Nonparticipating provider

    • B. 

      Out-of-network provider

    • C. 

      Participating provider

    • D. 

      Value-added provider


  • 19. 
    Which is an interpretation of the birthday rule regarding two group health insurance policies when the parents of a child covered on both policies are married to each other and live in the same household?
    • A. 

      The parent whose birth month and day occurs earlier in the calender year is the primary policy holder

    • B. 

      The parent who was born first is the primary policy holder

    • C. 

      Both parents are primary policy holders

    • D. 

      The parent whose income is higher is the primary policy holder


  • 20. 
    Which is the financial record source document usually generated by a hospital? 
    • A. 

      Chargmaster

    • B. 

      Day sheet

    • C. 

      Encounter form

    • D. 

      Superbill


  • 21. 
    (Refer to figure 4-20 of chapter 4) Which payers claim should be followed up first to obtain reimbursement?
    • A. 

      Aetna California

    • B. 

      Blue Cross Blue Shield Florida

    • C. 

      Home Health Agency

    • D. 

      Medicaid


  • 22. 
    Which protects information collected by consumer reporting agencies?
    • A. 

      Equal Credit Opportunity Act

    • B. 

      Fair Credit Reporting Act

    • C. 

      Fair Dept Collection Practices Act

    • D. 

      Truth In Lending Act


  • 23. 
    Which protects information collected by consumer reporting agencies?
    • A. 

      Equal Credit Opportunity Act

    • B. 

      Fair Credit Reporting Act

    • C. 

      Fair Debt Collection Practices Act

    • D. 

      Truth In Lending Act


  • 24. 
    Which is the best way to prevent delinquent claims?
    • A. 

      Attach supporting medical documentation on claims

    • B. 

      Enter all claims data in the in the practices suspense file

    • C. 

      Submit closed claims to all third-party payers

    • D. 

      Verify all health plan identification information on all patients


  • 25. 
    Which is a characteristic  of delinquent commercial claims awaiting payer reimbursement?
    • A. 

      Delinquent claims are outsourced to a collection agency

    • B. 

      The delinquent claims are resolved directly with the payer

    • C. 

      The accounts receivable aging report was not submitted

    • D. 

      The provided remittance notice was delayed by the payer


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