Deck 7: Health Care Claim Preparation and Transmission

Question 1

In which of these methods of transmitting claims can employees key standard data elements using an Internet-based service?

A) direct data entry
B) the adjudication process
C) clearinghouse use
D) direct transmission to the payer

Answer 1

direct data entry

Question 2

What is the payer's responsibility sequence number for the payer of last resort?

A) L
B) P
C) S
D) T

Answer 2

T

Question 3

What item is not included in the patient information section lines 1-13 of the CMS-1500?

A) the health plan
B) the insured
C) the patient
D) the diagnosis

Answer 3

the diagnosis

Question 4

What are the five sections on a claim?

A) provider, claim details, diagnosis, procedure, payer
B) provider, payer, diagnosis, clearinghouse, subscriber
C) provider, subscriber, payer, claim details, services
D) provider, clearinghouse, payer, claim details, diagnosis

Question 5

A HIPAA-mandated electronic transaction for claims may also be called

A) HCFA1500.
B) HIPAA X12 837 Health Care Claim.
C) EDI.
D) CMS1500.

Question 6

Choose the editing software programs used to check claims for error correction.

A) claim scrubbers
B) clearinghouses
C) claim checkers
D) claim transmitters

Question 7

Name the electronic format that practices use to ask payers about claims.

A) HIPAA claim
B) HIPAA X12 837
C) CMS-1500
D) HIPAA X12 276/277

Question 8

Claims that are acceptable for adjudication by payers are called

A) simple claims.
B) clear claims.
C) standard claims.
D) clean claims.

Question 9

The physician who actually provided the service is the

A) billing provider
B) pay-to provider
C) destination payer.
D) rendering provider

Question 10

For the release of information to be permissible, signature on file must have been obtained

A) within two years.
B) within six months.
C) within three years.
D) within 12 months.

Question 11

You are working for a practice and need to include a data element on a claim because it is required by the contract with the payer. Determine which of the following data element types needs to be included in this situation.

A) NRUC
B) R
C) NR
D) RIA

Question 12

Which qualifier would be reported in Item Number 15 to indicate the date being reported is last x-ray?

A) 439
B) 454
C) 444
D) 455

Question 13

What entity is the destination payer?

A) the patient who is receiving a payment from a health plan
B) the health plan receiving a HIPAA claim
C) the provider that is receiving a payment from a health plan
D) the provider who is seeing the patient

Question 14

Identify the claim filing indicator code that is used to indicate that the health plan is Medicaid.

A) MC
B) OF
C) AM
D) MB

Question 15

Assume that three providers are indicated for a claim for lab services. A clearinghouse is the billing provider and the physician practice is the pay-to provider. What type of provider is the laboratory?

A) the destination provider
B) the model provider
C) the rendering provider
D) the referring provider

Question 16

A billing service sending a claim is likely to be the

A) referring provider.
B) destination payer.
C) pay-to provider.
D) billing provider.

Question 17

What is sent as additional data to support a claim?

A) attachment
B) National Uniform Claim Committee number
C) PHI
D) procedure code

Question 18

Name the function of the carrier block.

A) It allows for a four-line address for the payer.
B) It allows the payer to make notes.
C) It allows for a four-line address for the patient.
D) It allows the payer to input their own codes.

Question 19

You are working at a practice and need to submit a claim, but cannot reach a patient to obtain his or her address, which is not on file. What should you do?

A) Do not submit the claim until you are able to retrieve the patient's address
B) Submit the claim using the practice's address in place of the patient's address'
C) Submit the claim with "Unknown" entered for the patient's address.
D) Submit the claim with the patient's address left blank.

Question 20

Under HIPAA, payers may not

A) restrict what clearinghouse used.
B) restrict what the PMP office uses.
C) refuse to accept the standard transactions.
D) delay payment of a non-compliant claims.

Question 21

The person or company that provides or supervised the care is known as the __________.

A) Main Provider
B) Rendering Provider
C) Consulting Provider
D) Ordering Provider

Question 22

HIPAA EDI transactions must comply with

A) 5010A1 version.
B) 4010 version.
C) any version.
D) payer's version.

Question 23

When the patient and insured are not the same person, what type of code is required to indicate this fact?

A) individual relationship code
B) NRUC code
C) diagnosis code
D) data element code

Question 24

What information might be recorded in Item Number 25?

A) the physician's or supplier's EIN or SSN
B) the legacy number
C) the physician's NPI number
D) the referring physician's NPI number

Question 25

A data element that HIPAA mandates reporting under certain conditions is called a(n)

A) NRUC data element.
B) situational data element.
C) not required data element.
D) required data element.

Question 26

Identify the claim filing indicator code that is used to indicate a self-pay patient.

A) 12
B) 10
C) 09
D) 11

Question 27

When the subscriber and the patient are the same person, what patient data is required on the HIPAA 837?

A) the information must be duplicated in both sections
B) the subscriber data is not required if the subscribed and the patient are the same
C) the patient data is not required if the subscribed and the patient are the same
D) none of these are correct; the subscriber and the patient cannot be the same

Question 28

What is the purpose of the shading in the top portions for the six service lines in Section 24 of the CMS-1500 claim form?

A) to allow the payer to input notes
B) to allow the provider to include a proprietary identifier in addition to the NPI and in some cases, other supplemental data
C) there is no purpose for the shading in that section
D) to allow the billing of twelve lines of service

Question 29

How many characters can be entered into the Other ID# field in Line Number 17a?

A) 2
B) 4
C) 17
D) 10

Question 30

What does a claim filing indicator code identify?

A) the physician's diagnosis
B) the name of the health plan
C) the type of health plan
D) the procedures that were performed

Question 31

Name the POS code used to indicate a procedure occurred in a skilled nursing facility.

A) 11
B) 31
C) 12
D) 81

Question 32

Identify what is indicated by an individual relationship code.

A) the subscriber's insurance plan
B) the subscriber's relationship to the subscriber
C) the patient's relationship to the subscriber
D) the patient's relationship to the provider

Question 33

In Item Number 17, if multiple providers are involved what is the order of priority for entering providers?

A) referring provider, ordering provider, supervising provider
B) ordering provider, referring provider, supervising provider
C) referring provider, supervising provider, ordering provider
D) supervising provider, ordering provider, referring provider.

Question 34

Section 24 of the CMS-1500 records service line information, which contains the

A) procedures performed for the patient.
B) diagnoses made by the physician.
C) patient's name and address.
D) referring provider NPI number.

Question 35

A data element that HIPAA always mandates reporting is called a(n)

A) required data element.
B) situational data element.
C) not required data element.
D) NRUC data element.

Question 36

Identify the person or organization that receives payment.

A) the destination payer
B) the referring provider
C) the billing provider
D) the pay-to provider

Question 37

What organization determines the content of both HIPAA 837 and CMS-1500 claims?

A) HIPAA
B) NPI
C) NUCC
D) CMS

Question 38

Which of the following is a valid tip for entering data?

A) Use only valid data in all fields.
B) Use prefixes for people's names.
C) Use hyphens, dashes, spaces, special characters, or parentheses in telephone numbers.
D) Use a dash, space, or special character in a Zip code field.

Question 39

Correct medical code sets are those that are

A) valid at the time the service was performed.
B) valid when the claim is paid.
C) valid when the claim is processed.
D) valid based on payers guidelines.

Question 40

You are reporting an unlisted procedure code that requires a very lengthy narrative description. Determine the best way to present this information to the payer.

A) Provide a special report.
B) Write a description in the margin of the CMS-1500 claim form.
C) Wait until information is requested from the payer.
D) Write part of the description in Item Number 19 as space allows.

Question 41

When nonspecific procedure codes such as unlisted CPT codes are used, the claim must contain

A) extra diagnosis codes.
B) HCPCS codes.
C) modifiers.
D) service-line level description of the work or drug/dosage.

Question 42

Name the condition code you would apply to an abortion performed due to social or economic reasons.

A) AF
B) AH
C) AG
D) AE

Question 43

What character should be used in Item Number 24F if the encounter was under an MCO capitation contract?

A) C
B) 0
C) both C and 0
D) $

Question 44

The provider who provides the procedure on a claim other than the pay-to provider is called the

A) billing provider.
B) primary provider.
C) rendering provider.
D) referring provider.

Question 45

Physicians identify their medical specialty by using

A) administrative codes.
B) place of service codes.
C) taxonomy codes.
D) diagnosis codes.

Question 46

Explain the purpose of Item Number 10a-10C on the CMS-1500.

A) to determine liability for the condition
B) to determine the need for additional services
C) this field is not required
D) to determine the patient's availability for appointments

Question 47

Determine where you would report a service that was performed by an outside laboratory on the CMS-1500.

A) Item Number 21
B) Item Number 20
C) Item Number 19
D) Item Number 22

Question 48

How many diagnosis codes may be reported on the HIPAA 837?

A) eight
B) four
C) six
D) twelve

Question 49

Which of the following is a circumstance under which the last-seen date is not required to be reported on the HIPAA 837 claim?

A) the timing and/or frequency of visits affects payment for services
B) a physician's services involving routine foot care
C) original date seen
D) a claim involves an independent physical therapist's or occupational therapist's services

Question 50

Which of the following codes must be used to indicate that a procedure took place in a medical office?

A) place of service codes
B) taxonomy codes
C) administrative codes
D) diagnosis codes

Question 51

Examine the following entities and determine which may act as a billing provider.

A) only a billing service and clearinghouse
B) only a practice and billing service
C) only a clearinghouse and practice
D) a clearinghouse, practice, and billing service

Question 52

How many different types of providers may need to be identified?

A) five
B) three
C) four
D) two

Question 53

Why has sending paper claims become less common?

A) patients began requesting the use of less paper claims
B) insurance companies do not require claims to be submitted
C) the increased use of information technology as mandated by CMS and HIPAA
D) increased costs of paper and mail delivery

Question 54

Which of the following must be supplied by the provider on every claim?

A) not required unless specified under contract data element
B) required if applicable data element
C) not required data element
D) required data element

Question 55

In what format can claim attachments be sent?

A) claim attachments cannot be sent with the claim
B) paper format only
C) electronic or paper format
D) electronic format only

Question 56

Which of the following explains a reason that the five levels of the HIPAA 837 are set up as a hierarchy?

A) None of these are correct.
B) The most important information on the HIPAA 837 appears first.
C) So that when the claim is sent electronically, the only data elements that have to be sent are those that do not repeat previous data.
D) To conform with the order that payers demand the information to be transmitted.

Question 57

Which of the following skills are required of medical insurance specialists in completing claims?

A) critical thinking skills and A/P
B) medical terminology and memorization
C) memorization
D) organizational skills and good thinking skills

Question 58

What type of signature should be used in Item Number 31?

A) legal signature of the practitioner
B) signature of the practitioner representative
C) SOF
D) all of these

Question 59

Explain how a payer will respond to a claim that does not contain at least one diagnosis code.

A) The payer will provide the code they deem most appropriate.
B) The payer will deny the claim.
C) None of these are correct.
D) The payer will call the practice and ask for the code.

Question 60

What choice may be made in Item Number 6 to show that the insured is the patient?

A) Spouse
B) Other
C) Child
D) Self

Question 61

Which of the following is the HIPAA-mandated electronic transaction for claims from physicians and other medical professionals?

A) 847P
B) 837I
C) 847I
D) 837P

Question 62

Determine what was not required of PMP vendors when the HIPAA 837 electronic transaction was mandated.

A) receiving certification from HIPAA testing vendors that their software can accommodate HIPAA-mandated transactions
B) providing updates at no additional cost
C) maintaining up-to-date software products
D) training office personnel in the use of new features

Question 63

Name the current paper claim approved by the NUCC.

A) CMS-1500
B) CMS-1500 (02/12)
C) 837
D) HIPAA 837 claim

Question 64

You are working at a practice and need to decide whether or not you may release a medical document about a patient in order to process a claim. Determine where to find this information on the CMS-1500.

A) Item Number 12
B) Item Number 9
C) Item Number 13
D) Item Number 8

Question 65

On a HIPAA claim, which of the following is assigned to a particular service being reported?

A) a line item control number
B) a claim control number
C) either claim control number or line item control number
D) neither claim control number nor line item control number

Question 66

You are working at a medical practice and have been requested to resubmit a claim to replace one that was sent the previous week. Determine what claim frequency code should be applied to the claim.

A) 1
B) no frequency code is required
C) 8
D) 7

Question 67

In which of these methods of transmitting claims do providers and payers exchange transactions directly without using a third party?

A) clearinghouse use
B) the adjudication process
C) direct data entry
D) direct transmission to the payer

Question 68

What information about an accident is not required to be reported on the HIPAA 837 claim?

A) the state or country in which the accident occurred
B) the date and time of the accident
C) the type of accident
D) the name of the person who caused the accident

Question 69

The insured's ID number is the

A) payer's identification number.
B) physician's NPI.
C) physician's legacy number.
D) identification number of the policy holder.

Question 70

What type of code may not be required by HIPAA, but if used, must be chosen from the NUCC list?

A) administrative codes
B) place of service codes
C) diagnosis codes
D) taxonomy codes

Question 71

The responsible party is held accountable for

A) the financial responsibility for a bill.
B) the correct completion of the HIPAA 837.
C) the correct assignment of codes.
D) the submission of the electronic claim.

Question 72

Correct administrative code sets for claims are those that are

A) valid at the time the transaction is started.
B) valid only if sent electronically.
C) valid at the time the transaction has ended.
D) valid only if it is necessary to appeal the claim.

Question 73

What is the most common method of claim transmission?

A) direct data entry
B) direct transmission to the payer
C) clearinghouse use
D) the adjudication process

Question 74

You are completing a CMS-1500 and realize that a husband has additional coverage under his wife's policy. Determine where you would record the wife's name on the CMS-1500 for the additional insurance.

A) Item Numbers 10a-10c
B) Item Number 8
C) Item Number 11d
D) Item Number 9

Question 75

Which of the following supplemental information can not be entered into the shaded areas of Item Number 24?

A) narrative description of unspecified code
B) tooth numbers
C) provider address
D) NDCs for drugs

Question 76

Identify the important step that immediately precedes claim transmittal.

A) getting patient approval
B) checking the claim
C) notifying the patient
D) notifying the payer

Question 77

Name the POS code used to indicate a procedure occurred in an on campus-outpatient hospital.

A) 24
B) 22
C) 21
D) 23

Question 78

A payer requires the provider to list specific identifiers supplemental claim information on the CMS-1500. Determine the most likely place they would require this information to be reported.

A) Item Number 19
B) Item Number 24
C) Item Number 20
D) Item Number 22

Question 79

Which of the following is a data element that is required on the HIPAA 837P claim?

A) THE balance due
B) THE billing provider name and telephone number
C) THE physician's signature
D) THE insured's marital status and gender

Question 80

The electronic transmission of claims is not required by law if a practice never sends any kind of electronic health care transactions, and has less than __________ full-time or equivalent employees.

A) fifty
B) ten
C) five
D) twenty