Deck 3: Introduction to Claims Processing

Question 1

The typical _______________ payment structure is where a provider will bill for all services rendered to the third-party payer after the services have been provided and then the third-party payer, retrospectively, will pay the provider.

A) fee-for-service
B) episode-of-care
C) block payment
D) capitation

Answer 1

A

Question 2

Currently, we are in a prospective payment environment and have various forms of payment, such as:

A) managed care.
B) episode-of-care.
C) capitation.
D) global payment.
E) All of these are correct.

Answer 2

E

Question 3

For pricing purposes, the ANSI X12N 837 P (837P) Electronic Claim Form, when the Place of Service (POS) is listed as __________, and the pricing will be based on where the beneficiary's home is located.

A) 10
B) 11
C) 12
D) 24
E) None of these is correct.

Answer 3

C

Question 4

If ____________ ambulance(s) transported the patient from the initial pick-up location to the final destination, the jurisdiction is with the carrier that is at the point of origin of the ambulance.

A) three
B) two
C) one
D) None of these is correct.

Question 5

Carrier jurisdiction for claims involving individuals who are part of the Railroad Retirement Beneficiary includes those who are entitled to both ______________ and railroad retirement benefits.

A) Medicare
B) Medicaid
C) Blue Cross and Blue Shield
D) Social Security
E) None of these is correct.

Question 6

The agency or facility providing the care to the patient will be responsible for payment of the supplies that are covered under Part B, as they are covered under the payment for:

A) Prospective Payment System (PPS).
B) Diagnosis-Related Group (DRG).
C) Ambulatory Payment Classification (APC).
D) Home Health Resource Groups (HHRG).

Question 7

Charges to the beneficiary for admission or readmission are not allowable, however, there is an exception when a resident leaves a skilled nursing facility (SNF):

A) against medical advice.
B) temporarily.
C) upon discharge to home.
D) None of these is correct.

Question 8

A financial relationship includes both ownership and investment interests, along with compensation arrangements that include contractual arrangements between a ____________________ and ______________________ for physician services.

A) a hospital and a Health Maintenance Organization (HMO)
B) a physician and a Physician-Hospital Organization (PHO)
C) a hospital and a physician
D) a Managed Care Organization (MCO) and a PHO

Question 9

The Advance Beneficiary Notice (ABN) cannot have italics or any font that is difficult to read and must be:

A) at least 12-point font size.
B) in dark ink.
C) legibly handwritten.
D) All of these are correct.
E) None of these is correct.

Question 10

A(n) __________________ is a beneficiary who can comprehend the notice.

A) capable recipient
B) incompetent person
C) comatose person
D) person under duress

Question 11

ABNs given to a patient or authorized representative who is under _______________ cannot be considered a proper notice.

A) great duress
B) a non-emergent situation
C) both great duress and a non-emergent situation
D) None of these is correct.

Question 12

A request for redetermination must be filed within ____ days after receiving the notice of the initial determination.

A) 90
B) 60
C) 120
D) 180

Question 13

The appeals process consists of ____________ levels; each level must be completed for each claim at issue prior to proceeding to the next level.

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

Question 14

An appeal letter should be formatted in all of the following ways, except:

A) spell out all dates.
B) use a small font size no larger than 10.
C) use bullet points.
D) spell out procedures.

Question 15

A supplier is a physician or other practitioner, or an entity other than a provider who furnishes healthcare services under Medicare, and must meet certain requirements as outlined in the Medicare Program Integrity Manual.

Question 16

When not using the POS 12, the claim processing and pricing calculations will be based on the service location.

Question 17

If a supplier operates mobile units for X-ray and other portable services in multiple MAC DMEs, then the permanent address for where the beneficiary received services will determine which carrier will process the claim.

Question 18

In the agreement/attestation statement signed by a provider, it agrees to charge Medicare beneficiaries for any services which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program.

Question 19

In the provider agreement between CMS and the provider, the provider agrees to promptly refund any money that they incorrectly collected from the Medicare beneficiary.