Insurance Health Basics/Health Insurance Claim Form-hi-1011 Chapters 17 & 18

The explanation for the given correct answer is that the birthday rule is a common practice in the insurance industry. When an individual is covered by multiple insurance policies, the policyholder whose birthday comes first in the calendar year is considered the primary insurance. This means that their insurance plan will be the first to cover any medical expenses, while the secondary insurance will cover the remaining costs. This rule helps determine the order in which insurance policies should be billed and ensures that there is no confusion or overlap in coverage. Therefore, the statement is true.

The statement "There is no difference if a patient is in or out of network" is false. Being in or out of network can have significant differences in terms of cost, coverage, and access to healthcare providers. In-network providers have negotiated rates with insurance companies, resulting in lower out-of-pocket costs for patients. Out-of-network providers, on the other hand, may not be covered by insurance or may require higher deductibles and co-pays. Additionally, being in-network ensures that patients have access to a wider network of healthcare providers and facilities.

The CMS1500 form is considered a universal claim form because it is used by healthcare providers to submit claims for reimbursement to insurance companies. It is accepted by most insurance carriers and is widely recognized as the standard form for submitting medical claims. This form includes important information such as patient demographics, medical diagnosis, and treatment codes, making it an essential tool for healthcare providers to accurately and efficiently process claims.

Medicaid is a joint federal and state program that provides health insurance to low-income individuals and families. It is funded by both the federal government and individual states, with the federal government setting basic guidelines and each state having the flexibility to determine eligibility criteria and benefits within those guidelines. Therefore, Medicaid can be considered as both federal and state health insurance.

The UCR formula, also known as Usual, Customary, and Reasonable formula, is indeed used by insurance companies to determine the fee schedule. This formula helps insurance companies determine the maximum amount they will reimburse for a particular medical service or procedure based on what is considered usual, customary, and reasonable in a specific geographic area. By using this formula, insurance companies can establish a standard fee schedule that aligns with the prevailing costs in a given area.

Group coverages are not necessarily more expensive just because they cover a larger group of individuals. The cost of insurance depends on various factors such as the type of coverage, the level of risk associated with the group, and the specific terms and conditions of the policy. While it is possible for group coverages to be more expensive due to the larger number of individuals covered, this is not always the case. Other factors can also influence the cost of group coverages, such as the negotiating power of the group or the specific benefits and coverage limits included in the policy. Therefore, the statement that group coverages are more expensive solely because they cover a larger group is false.

CMS1500 used to be referred to as HCFA1500. This statement is true. The CMS1500 form is a standard claim form used by healthcare professionals to bill Medicare and Medicaid. It was previously known as the HCFA1500 form, named after the Health Care Financing Administration, which was the predecessor of the Centers for Medicare and Medicaid Services (CMS). The name change occurred in 2001 when the agency was reorganized and renamed.

Electronic claim processing commonly uses the 837P format for billing. This format is specifically designed for professional healthcare providers to submit claims electronically. It includes all the necessary information such as patient demographics, diagnosis codes, procedure codes, and insurance information. Using the 837P format streamlines the billing process, reduces errors, and allows for faster claim processing and reimbursement. Hence, the statement "Electronic claim processing uses an 837P format for billing" is true.

A suspended claim with an insurance company that could eventually be denied or paid is considered a pending claim. This means that the claim is currently being reviewed or investigated by the insurance company and a decision on whether to approve or deny the claim has not yet been made.

The statement is false because the patient cannot choose which insurance can be billed first if they are covered under more than one insurance. The order in which the insurance companies are billed is determined by a process called coordination of benefits, which follows specific rules and guidelines set by the insurance companies. The primary insurance is typically billed first, followed by the secondary insurance, if applicable. The patient does not have the authority to decide the billing order.

The correct answer is "rejected". When a claim is returned from the insurance company with a code, it indicates that the claim has been rejected. This means that the insurance company has determined that the claim does not meet the necessary criteria for coverage and will not provide payment for the claim.

The statement "Managed care has high out of pocket costs" is false. Managed care plans typically have lower out of pocket costs compared to other types of health insurance plans. Managed care plans often have co-pays for doctor visits and prescriptions, and they may also have deductibles and co-insurance. However, these costs are generally lower and more predictable compared to plans with higher out of pocket costs, such as fee-for-service plans.

The claim states that the information only pertains to the patient. However, without any specific context or additional information provided, it is not possible to determine whether the claim is true or false. Therefore, the correct answer is false as it cannot be confirmed based on the given information.

This statement is true because in an office setting, it is possible to have multiple fee schedules that can be used for billing purposes. This allows for flexibility in charging different fees for different services or for different groups of patients. By having multiple fee schedules, the office can accurately and efficiently bill patients based on the specific services they receive, ensuring that the correct fees are applied.

Insurance companies do not utilize all the boxes on the claim form. This means that not all sections or fields on the form are used or required by the insurance company. Some boxes may be left blank or not applicable to the specific claim being submitted.

POS stands for place of service. This identifies the facility where services were performed.

Having an authorization from the insurance company does not guarantee that the provider will be paid. While authorization is typically required for insurance companies to cover the cost of certain medical services, it does not guarantee payment. The insurance company may still deny the claim or have certain limitations on coverage, such as deductibles or co-pays, which the provider may not be fully reimbursed for. Therefore, having authorization does not ensure payment from the insurance company.

A six digit format is incorrect. The rule is to use and eight digit format for the date of service, mm/dd/ccyy.

Disability policies can be issued as short term, mid term, and long term. This statement is false. Disability policies are typically categorized based on the duration of coverage they provide. Short-term disability policies usually provide coverage for a few months, while mid-term policies may cover a longer period, such as a year. Long-term disability policies, on the other hand, provide coverage for an extended period, often until retirement age. Therefore, disability policies can indeed be issued as short term, mid term, and long term.

A denied claim could be a result of it being applied to the deductible. The insurance company is denying payment because it is the patient's responsibility for the deductible.