Deck 13: Payments Ras, Appeals, and Secondary Claims

Question 1

The __________ verifies the medical necessity of providers' reported procedures.

A) claims processor
B) physician
C) claims examiner
D) auditor

Answer 1

claims examiner

Question 2

A payer's initial claim review may reject a claim due to

A) utilization review.
B) an invalid policy number.
C) lack of medical necessity.
D) noncovered services.

Answer 2

an invalid policy number.

Question 3

The first step the medical billing specialist should check when reviewing RAs is to

A) check each payment.
B) start the appeals process.
C) call or email the payer with identified problems.
D) match up claims with the RA using the unique claim control number.

Answer 3

match up claims with the RA using the unique claim control number.

Question 4

Which of these HIPAA transactions is sent by a payer to answer a question about a submitted claim?

A) 277
B) 837
C) 835
D) 276

Question 5

Which of these HIPAA transactions is sent by a payer to explain a claim payment?

A) 276
B) 277
C) 835
D) 837

Question 6

What may result from a lack of clear, correct linkage between the diagnosis and the procedure?

A) initial processing
B) medical necessity denial
C) redetermination
D) manual review

Question 7

What is the claim status when the payer is developing the claim?

A) development
B) determination
C) suspended
D) concurrent care

Question 8

RA is the abbreviation for

A) remittance advice.
B) results advice.
C) remittance allowed.
D) results allowed.

Question 9

On an aging report, which category describes a current invoice?

A) 61-90 days
B) 31-60 days
C) over 90 days
D) 0-30 days

Question 10

What happens if a provider does not provide an itemized statement to the Medicare beneficiary upon his/her request within thirty days?

A) The provider may be fined $100 per outstanding request.
B) Nothing because providers are not required to provide Medicare beneficiaries itemized statements.
C) The practice is closed for failure to respond.
D) The Medicare beneficiary is required to request an itemized statement again after thirty days.

Question 11

Claim adjustment reason codes are used by payers to explain entries on

A) HIPAA 277 transactions.
B) denials.
C) RAs.
D) aging reports.

Question 12

The person filing an appeal is known as a(n) __________, regardless of whether that individual is a provider or a patient.

A) either the claimant or the appellant
B) claimant
C) griever
D) appellant

Question 13

Remittance advice remark codes are maintained by __________ but can be used by all payers.

A) QIO
B) CMS
C) HIPAA
D) OIG

Question 14

Filing a grievance with the state insurance commission requires the __________ to investigate the complaint.

A) county
B) state
C) federal government
D) city

Question 15

Funds that are electronically transferred from a payer are directly deposited in the

A) fiscal intermediaries account.
B) physician's bank account.
C) patient's bank account.
D) practice's bank account.

Question 16

The term __________ during claim adjudication means that the payer needs more information to process the claim.

A) redetermination
B) suspended
C) determination
D) development

Question 17

Prompt-pay laws govern

A) physicians to pay pharmacies for medications.
B) patients to pay physicians for services.
C) physician practice payments of their suppliers' invoices.
D) insurance carriers' payments of providers' claims.

Question 18

Which of these codes might payers use to explain a determination?

A) claim adjustment group code
B) all of these answers are correct
C) remittance advice remark code
D) claim adjustment reason code

Question 19

A paper explanation of benefits (EOB) is sent to patients by payers after claims

A) are submitted.
B) are adjudicated.
C) are paid.
D) are denied.

Question 20

An aging report groups unpaid claims or bills according to

A) the amount of time left to pay.
B) the length of time that they remain due.
C) aging reports are not grouped together.
D) the amount of money due.

Question 21

Which of the following statements is true?

A) Either Medicare or Medicaid can be the secondary payer, as it will depend on the patient's plans.
B) Neither Medicare nor Medicaid will be the secondary payer.
C) Medicaid is the secondary payer to Medicare.
D) Medicare is the secondary payer to Medicaid.

Question 22

A typical aging report groups payments that are due into which of these categories?

A) 0-30 days, 31-60 days, 61-90 days, 91-120 days, and over 121 days
B) 0-60 days, 61-120 days, 121-180 days, over 180 days
C) 0-15 days, 16-30 days, 31-45 days, 45-60 days
D) 0-45 days, 46-90 days, 91-135 days, over 135 days

Question 23

During the adjudication process, if there are problems during the automated review, the claim is pulled for

A) determination.
B) development.
C) suspension.
D) pending status.

Question 24

A list of claims transmitted and how long they have been in process with the payer is shown in the

A) insurance log.
B) redetermination list.
C) insurance aging report.
D) patient aging report.

Question 25

If a Medicare beneficiary is employed and covered by the employer's group health plan, the Medicare plan is

A) neither primary nor secondary.
B) primary.
C) secondary.
D) either primary or secondary.

Question 26

Claim adjustment reason codes are found on

A) the insurance aging report.
B) RAs.
C) accounts receivable reports.
D) the patient medical record.

Question 27

From the payer's point of view, __________ are improper or excessive payments resulting from billing errors for which the provider owes refunds.

A) grievances
B) overpayments
C) claimants
D) errors

Question 28

Medical situations in which a patient receives extensive care from two or more providers on the same date of service are called

A) bundled care.
B) E/M services.
C) global period servicers.
D) concurrent care.

Question 29

If a medical practice believes that it has been treated unfairly by an insurance company, it has the right to file a __________ with the state insurance commission.

A) claim
B) lawsuit
C) complaint
D) grievance

Question 30

What kind of code appears on payers' electronic reports on the progress of transmitted claims in their adjudication process?

A) remittance advice remark codes
B) MOA remark codes
C) claim status category codes
D) claim adjustment reason codes

Question 31

The __________ of a claim refers to the payer's decision regarding payment.

A) determination
B) redetermination
C) autoposting
D) claimant

Question 32

__________ follow up on claims that are not processed within the specified claim turnaround time for the payer.

A) Medical insurance specialists
B) Medical coders
C) Medical technicians
D) Physicians

Question 33

Minor errors found by the practice on transmitted claims require which of the following?

A) corrections by asking the payer to reopen the claim and make the changes
B) corrections by asking the payer to adjust the charges
C) a denial
D) a completely new claim to be filed

Question 34

The payer sends the medical practice

A) a separate RA and an individual EOB for each claim processed.
B) only an RA upon request.
C) a separate RA for each processed claim.
D) an RA that covers a batch of processed claims.

Question 35

An insurance aging report lists

A) amounts patients still owe the physician.
B) unpaid claims transmitted to payers by the length of time they remain due.
C) the practice's patients, their insurance information, and their ages.
D) the amount of supplies the practice needs to pay for.

Question 36

When a claim is pulled by a payer for a manual review, the provider may be asked to submit

A) revised procedure codes.
B) clinical documentation.
C) a new diagnosis.
D) revised charges.

Question 37

How often are claim adjustment reason codes and remark codes updated?

A) annually
B) three times per year
C) quarterly
D) never

Question 38

A(n) __________ claim status category code is an acknowledgment that the claim has been received.

A) P
B) F
C) E
D) A

Question 39

RAs generally have information on any

A) errors on the listed claims.
B) all of these are correct.
C) adjustments to the listed claims.
D) denials to the listed claims.

Question 40

A medical practice may choose to __________ a rejected or partially paid claim.

A) appeal
B) neither resubmit nor appeal
C) either appeal or resubmit
D) resubmit

Question 41

If Medicare is the secondary payer, the claim must be submitted using the

A) HIPAA 276/277.
B) HIPAA 837P.
C) HIPAA 835.
D) CMS-1800.

Question 42

If a patient has additional insurance coverage, after the primary payer's RA has been posted, the next step is

A) billing the second payer.
B) waiting until the patient pays.
C) waiting until the primary insurance bills the second payer.
D) determining what the write off amount is.

Question 43

Which of these HIPAA transactions is used by medical offices to ask payers about the status of submitted claims?

A) 835
B) 276
C) 837
D) 277

Question 44

A payer's automated claim edits may result in claim denial because of

A) lack of eligibility for a reported service.
B) lack of required preauthorization.
C) lack of medical necessity.
D) any of these.

Question 45

Concurrent care is care provided

A) at the same place of service by two or more physicians.
B) at the same place as a previous visit.
C) by two physician practices on the same date by two physicians.
D) to a patient on the same date at the same place of service by two or more physicians.

Question 46

The __________ is the person or entity who seeks to receive benefits via an appeal.

A) claimant
B) defendant
C) attorney
D) plaintiff

Question 47

The claim turnaround time is stated

A) payers do not have to publish this information.
B) in payer's policy manuals or contracts.
C) on the payer's website.
D) on the back of the patient's card.

Question 48

What is done by a payer to determine the appropriateness of medical services?

A) concurrent care
B) development
C) utilization review
D) determination

Question 49

If a Medicare beneficiary receives treatment covered by workers' compensation, the Medicare plan is

A) neither primary nor secondary.
B) primary.
C) either primary or secondary.
D) secondary.

Question 50

What is the correct order for the basic steps of a payer's adjudication process?

A) initial processing, automated review, manual review, determination, and payment
B) initial processing, manual review, automated review determination, and payment
C) manual review, initial processing, automated review, determination, and payment
D) automated review, initial processing, manual review, determination, and payment

Question 51

In general, how many levels are there when pursuing an appeal?

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

Question 52

A payer's decision regarding whether to pay, deny, or partially pay a claim is called

A) evaluation.
B) determination.
C) utilization.
D) adjudication.

Question 53

What will a payer do when a claim is submitted with a diagnosis code that is not valid for the date of service?

A) Payers may deny a claim when outdated codes are used.
B) Payers will not respond to the claim.
C) Payers are not permitted to deny a claim when outdated procedure codes are used.
D) Payers will typically pay and submit the claim to the provider with the correct procedure codes.

Question 54

The Medicare Secondary Payer program coordinates the benefits for patients who have both Medicare and

A) only additional Medicaid coverage.
B) only additional TRICARE coverage.
C) only other Medicare coverage.
D) any other insurance coverage.

Question 55

What does the abbreviation COB stand for?

A) Coordination of billing
B) Coordination of benefits
C) Cooperation of billing
D) Cooperation of benefits

Question 56

Medicare overpayments must be reported and the amount

A) must be returned within 60 days.
B) must be returned immediately.
C) does not exist, as Medicare does not make overpayments
D) does not have to be paid back.

Question 57

__________ is the process of determining whether to pay, reject, deny, or partially pay claims.

A) Determination
B) Adjudication
C) Redetermination
D) Appealing

Question 58

What code indicates an error has occurred in transmission?

A) F
B) P
C) A
D) E

Question 59

An __________ code indicates that a request for more information has been sent.

A) F
B) E
C) R
D) A

Question 60

A payer may __________ a procedure that it determines was not medically necessary at the level reported.

A) bundle
B) concurrent code
C) upcode
D) downcode

Question 61

What does "reconciliation" mean?

A) the insurance paid the amount that they owed
B) to double-check that totals are accurate and consistent
C) to have good communications between the physician practice and payers
D) the patient paid the amount that he/she owed

Question 62

If a Medicare beneficiary is covered by a spouse's employer group health plan, the Medicare plan is

A) primary.
B) secondary.
C) either primary or secondary.
D) neither primary nor secondary.

Question 63

The claimant is the

A) patient who appeals the claim.
B) provider who appeals the claim.
C) payer's employee who heads the medical review program.
D) patient or provider who appeals the claim.

Question 64

Which of the following is an example of concurrent care?

A) a case in which a patient is seen in the emergency room and then admitted by a different doctor to the floor
B) a case in which a patient is attended by two physicians, such as a cardiologist and a thoracic surgeon, during surgery
C) a case in which a patient is seen in the emergency room and transferred across town to a different facility
D) a case in which a nurse practitioner sees the patient and then transfers the care to a physician

Question 65

A pending claim is indicated by which claim status category code?

A) F
B) E
C) P
D) A

Question 66

__________ is a feature of some medical billing programs that automatically records payments in the correct accounts.

A) Autoposting
B) Determination
C) EFT
D) Reconciliation

Question 67

When is an appeal sent to third-party payers?

A) before a questionable claim is transmitted
B) after a claim is rejected or paid at less than the expected amount
C) after a claim is submitted
D) after a claim is paid

Question 68

What do MOA remark codes explain?

A) insurance aging report
B) Medicare payment decisions
C) concurrent care that was given
D) denials from claims

Question 69

The process of __________ means verifying that the totals on the RA are mathematically correct.

A) determination
B) reconciliation
C) autoposting
D) redetermination

Question 70

A __________occurs when a procedure and a diagnosis are not correctly linked, in the opinion of the payer.

A) redetermination
B) development
C) determination
D) medical necessity denial

Question 71

If a Medicare beneficiary receives treatment for an accident-related claim, the Medicare plan is

A) either primary or secondary.
B) secondary.
C) primary.
D) neither primary nor secondary.

Question 72

The claim turnaround time is the period between

A) the patient's encounter and the transmission of the resulting claim.
B) the patient's encounter and the date it was billed to the insurance.
C) the date the claim was paid by insurance to the time the patient paid his/her portion.
D) the date of claim transmission and receipt of payment.

Question 73

The abbreviation MRN stands for

A) Medicare Reinstatement Notice.
B) Medicare Redetermination Notice.
C) Medicare Rejection Notice.
D) Medicare Reconciliation Notice.

Question 74

The advantage(s) of EFT for practices is(are)

A) funds are available immediately and the transfer is less costly than check deposits.
B) the transfer is less costly than check deposits.
C) funds are available immediately.
D) neither funds are available immediately nor the transfer is less costly than check deposits.

Question 75

A Medicare Redetermination Notice explains

A) Medicare's unfavorable or partially favorable response to a request for redetermination.
B) Medicare's positive response to a request for redetermination.
C) Medicare's fines imposed after an audit.
D) Medicare's findings after an audit.

Question 76

In the appeals process, calendar days are considered

A) all days, including weekends.
B) Saturday and Sunday.
C) work days only.
D) Monday-Thursday.

Question 77

The payer's RA shows

A) the amount the provider is allowed.
B) the amount the patient pays.
C) both the amount the provider is allowed and the amount patient pays.
D) neither the amount the provider is allowed nor the amount the patient pays.

Question 78

A finalized claim is indicated by which claim status category code?

A) E
B) A
C) P
D) F

Question 79

When a payer's RA is received, the medical insurance specialist

A) does nothing, as these services are all computerized.
B) deposits that payment into the patient's bank account.
C) checks that the amount paid matches the expected payments.
D) sends the patient a refund of what the patient already paid.

Question 80

A payer's determination means it is going to

A) pay, deny, or partially pay the claim.
B) suspend the claim.
C) review the claim.
D) none of these are correct.