Understanding Health Insurance
Mid term practice test.
- 1.
A health care practioner is also called a:
- A.
Dealer
- B.
Provider
- C.
Perveyor
- D.
Supplier
Correct Answer
B. Provider -
- 2.
The process of assigning diagnoses, procedures, and services using numeric and alphanumeric characters is called:
- A.
Data processing
- B.
Coding
- C.
Reimbursement
- D.
Programming
Correct Answer
B. Coding -
- 3.
If health plan preauthorization requirement are not met by providers,
- A.
Administrative cost are reduced.
- B.
Payment of the claim is denied.
- C.
They pay a fine to the health plan.
- D.
Patient's coverage is cancelled.
Correct Answer
B. Payment of the claim is denied. -
- 4.
Which coding system is used to report diagnoses and conditions on claims?
- A.
National codes
- B.
ICD
- C.
HCPCS
- D.
CPT
Correct Answer
B. ICD -
- 5.
Which report is sent to the patient to detail the results of claims processing?
- A.
Explanation of benefits
- B.
Health insurance claim
- C.
Preauthorized form
- D.
Remittance advice
Correct Answer
A. Explanation of benefitsExplanation
EOB is a report details the "results" of processing a claim.Rate this question:
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- 6.
Remittance advice contains:
- A.
Payment information about a claim.
- B.
Provider qualifications and responsibilities.
- C.
Detected errors and omissions from claims.
- D.
Documentation of medical necessity.
Correct Answer
A. Payment information about a claim.Explanation
Document is either electronic or paper-based report of payment sent to the provider from the PAYER TO THE PROVIDERRate this question:
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- 7.
Medical malpractice insurance is a type of _______________ insurance.
- A.
Workers' compensation
- B.
Property
- C.
Liability
- D.
Bonding
Correct Answer
C. Liability -
- 8.
By 1880 , how many insurance companies offered health insurance policies?
- A.
10,000
- B.
500
- C.
1,000
- D.
60
- E.
40,
Correct Answer
D. 60Explanation
In 1880 expansion of private health insurance increased to 60 additional health insurance policies. Such policies covered loss of income & limited ills : smallbox,typhoid,scarlet fever)Rate this question:
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- 9.
Workers compensation is an insurance program that requires employers to cover medical expenses and
- A.
Create medical service bureaus.
- B.
Limit lifetime maximum amounts of coverage.
- C.
Provide lost wages for injured workers.
- D.
Implement prepaid health plan services.
Correct Answer
C. Provide lost wages for injured workers. -
- 10.
In what year were prepaid health health plans introduced?
- A.
1860
- B.
1908
- C.
1920
- D.
1946
Correct Answer
C. 1920Explanation
1860: fist commerical insurace company; 1908: birth of Works Compensation by Theodore Roosevelt; 1946: Blue Sheield symbol was created for Associatin Of Medical Care Plans - physician sponsored.Rate this question:
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- 11.
Health reform was initiated in 1930 when the _____ was funded by charitable organizations to address the concerns about the cost and distribution of medical care.
- A.
Wagner National Health Act
- B.
Hill - Burton Act
- C.
Committee on the cost of Medical Care ( CCMC )
- D.
Tatical Committe on Medical Care
Correct Answer
C. Committee on the cost of Medical Care ( CCMC ) -
- 12.
A commercial insurance company sends a letter to the physician requesting copy of a patient's entire medical record in order to process payment, No other documents accompany the letter. The Insurance Specialist should:
- A.
Contact the patient via telephon to alert him about the request.
- B.
Let the patient's physician handle the situation personally.
- C.
Make a copy of the record an mail it to the insurance company.
- D.
Require a signed patient authorization from the insurance company.
Correct Answer
D. Require a signed patient authorization from the insurance company. -
- 13.
Which is considered Medicare Fraud?
- A.
Billing for services that were not furnished and misrepresenting diafnoses to justify payment.
- B.
Charging excessive fees for services, equipment, or supplies provided by the physician.
- C.
Submitting claims for services that are not medically necessary to treat patient's condition.
- D.
Violating participating provider agreements with insurance companies and government programs.
Correct Answer
A. Billing for services that were not furnished and misrepresenting diafnoses to justify payment. -
- 14.
Which is considered Medicare Abuse?
- A.
Falsifying certifications of medical necessity, plans of treatment, and medical records to justify payment.
- B.
Improper billing practices that result in Medicare payment when the claim is the legal responsibility of another third party payer.
- C.
Soliciting, offering, or receiving a kickback for procedures and/or services provided to patients in the physician's office.
- D.
Unbundling codes: that is, reporting multiple CPT codes on a claim to increase reimbursement from a payer.
Correct Answer
B. Improper billing practices that result in Medicare payment when the claim is the legal responsibility of another third party payer. -
- 15.
A patient develps surgical complications and returns to the operating room to undergo surgery related to the orginal procedure. The return surgery is :
- A.
Billed as an additional surgical procedure.
- B.
Coded for office data capture purposes only.
- C.
Included at part of the original procedure.
- D.
Not reported on the CMS-1500 or UB-04 .
Correct Answer
A. Billed as an additional surgical procedure. -
- 16.
Outpatient surgery and surgeon charges for inpatient surgery are billed according to a global fee. Which means that the presurgical evaluation an mangement, initial and subsequent hospital visits, surgical procedure, discharge visit, and uncomplicated postoperative followup care in the surgeon's office are billed as:
- A.
DRG payment - diagnosis -related group system that reimburses hospitals for inpatient stays.
- B.
Mulitple charges.
- C.
One charge.
- D.
Separate charges.
Correct Answer
C. One charge. -
- 17.
Which situtation requires the provider to write a letter explaining special circumstances?
- A.
A patients stay was prolonged due to medical or pychological complications.
- B.
Charges submitted to the payer are lower than the provider's normal fee (eg., -22 added to code).
- C.
Surgery defined as an inpatient procedure was performed while tha patient was in the hospital.
- D.
Surgery typically categorized as an office procedure was performed in the hosptital outpatient setting.
Correct Answer
A. A patients stay was prolonged due to medical or pychological complications. -
- 18.
When an X is entered on one or moreof the YES boxes in Block 10 of the CMS-1500 claim, payment might be the responsibility of a ________ insurance company.
- A.
Disability
- B.
Homeowner's
- C.
Life
- D.
Managed care
Correct Answer
B. Homeowner's -
- 19.
When a patient is covered by a large employer group health plan (EGHP) and Medicare, which is primary?
- A.
EGHP
- B.
Medicare
- C.
No distinction is made between the plans
- D.
The plan thast has been in place longest
Correct Answer
A. EGHP -
- 20.
When a child who is covered by two or more plans lives with his married parents, the primary policyholder is the parent:
- A.
Who is older
- B.
Who is younger
- C.
Whose birthday occurs first in the year.
- D.
Whose birthday occurs last in the year.
Correct Answer
C. Whose birthday occurs first in the year.Explanation
Birthday RuleRate this question:
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- 21.
When an insurance company uses the patient's social security number as the patient's insurance identification number, Block 1a of the CMS-1500 claim:
- A.
Contains the dashes associated with the SSN.
- B.
Contains the ID Number without dashes.
- C.
Is left blank, because SSN are private.
- D.
Can contain spaces or dashes when the number is entered.
Correct Answer
B. Contains the ID Number without dashes. -
- 22.
When the CMS-1500 claim requires spaces for entry of a date, the entry looks like which of the following?
- A.
MM DD YYYY OR MM DD YY
- B.
MM-DD-YYYY OR MM-DD-YY
- C.
MM/DD/YYYY OR MM/DD/YY
- D.
MMDDYYYY OR MMDDYY
Correct Answer
A. MM DD YYYY OR MM DD YY -
- 23.
When completing a CMS-1500 claim using computer software, text should be entered in ____ case.
- A.
Lower
- B.
Upper
- C.
Small caps
- D.
Title
Correct Answer
B. Upper -
- 24.
When the CMS-1500 requires a response to Yes or No entries, enter:
- A.
A checkmark
- B.
An X
- C.
Either an X or a checkmark
- D.
Nothing
Correct Answer
B. An X -
- 25.
When a SIGNATURE ON FILE is the appropriate entry for a CMS-1500 claim block, which is also acceptable as an entry?
- A.
FILED
- B.
S/F
- C.
SIGNED
- D.
SOF
Correct Answer
D. SOF -
- 26.
Block 14 of the CMS-1500 claim requires entry of the date the patien first experienced signs or symptoms of an illness or injury (or date of last menstrual period for obstetric visits). Upon completion of Jean Mandel's claim, you notice that there is no documentation of that date in the in the record. The provider does document that her pain began five days ago. Today is May 10, YYYY. What do you enter in block 14?
- A.
05 05 YYYY
- B.
05 10 YYYY
- C.
The word NONE
- D.
Nothing (leave the block blank)
Correct Answer
A. 05 05 YYYY -
- 27.
When Block 25 of the CMS-1500 contains the provider's EIN, enter _____ after the first two digits of the EIN (Employer Identification Number)
- A.
A hyphen
- B.
A space
- C.
No punctuation or space
- D.
The provider's SSN
Correct Answer
C. No punctuation or space -
- 28.
When a patient is covered by the same primary and seconday commercial health insuranceplan,
- A.
Complete and submit two CMS-1500 claims.
- B.
Mail the remittance advice to the payer.
- C.
Send the secondary CMS-1500, but not the primary claim.
- D.
Submit just one CMS-1500 to the payer.
Correct Answer
D. Submit just one CMS-1500 to the payer. -
- 29.
When entering the patient's name in Block 2 of the CMS-1500 claim, separate the last name, first name, and middle name, and middle intial (if known) with:
- A.
Commas
- B.
Hyphens
- C.
Slashes
- D.
Spaces
Correct Answer
A. Commas -
- 30.
Block 33a of the CMS-1500 claim contains the provider's:
- A.
Employer Identification Number (EIN)
- B.
National Provider's Number (NPI)
- C.
Provider's Identification Number (PIN)
- D.
Social Security Number (SSN)
Correct Answer
B. National Provider's Number (NPI) -
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Current Version
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Jan 10, 2013Quiz Edited by
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Feb 13, 2010Quiz Created by
Auilda
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