Quiz 4 :
Processing an Insurance Claim

Which means the provider agrees to accept what the insurance company allows or approves as payment in full for the claim?

Health insurance plans may include a(n) __________ provision, which means that when the patient has reached that limit for the year, appropriate patient reimbursement to the provider is determined.

Which best assists providers in the overall collection of appropriate reimbursement for services rendered?

Which person is responsible for paying the charges?

A participating provider (PAR) contracts with a health insurance plan and accepts whatever the plan pays for procedures or services performed. This means that PARs __________ allowed to bill patients for the difference between the contracted rate and their normal fee.

A nonparticipating provider (nonPAR) is an out-of-network provider who does not contract with the insurance plan, and patients who elect to receive care from non-PARs will incur higher out-of-pocket expenses. The patient __________ expected to pay the difference between the insurance payment and the provider's fee.

Dr. Smith is a participating provider (PAR) for the ABC Health Insurance Plan. Mary Talley is treated by Dr. Smith in the office, for which a $100 fee is charged. Given the information in the table located below, calculate the PAR provider write-off amount. PAR provider fee

Dr. Jones is a nonparticipating provider (nonPAR) for the ABC Health Insurance Plan. Anne Smith is treated by Dr. Jones in the office, for which a $100 fee is charged. Given the information in the table located below, calculate the nonPAR provider write-off amount. nonPAR provider fee

Which is the insurance plan responsible for paying health care insurance claims first?

Secondary insurance is the insurance plan that is billed after the primary insurance plan has paid its contracted amount and the provider's office has received a(n) __________ from the primary payer.

When a child lives with both parents, and each parent subscribes to a different health insurance plan, the primary and secondary policies are determined by applying the birthday rule. The individual who holds the primary policy for dependent children is the spouse whose birth __________.

When applying the birthday rule, if policyholders have identical birthdays, the policy in effect the __________ is considered primary.

A child is listed as a dependent on both his father's and his mother's group insurance policies. The father's birth date is March 20, 1977, and the mother's birth date is March 6, 1979. Which policy is primary?

Which is the financial record source document used by health care providers and other personnel to record treated diagnoses and services rendered to the patient during the current visit?

Which is the financial record source document used by health care providers and other personnel in a physician's office setting to record treated diagnoses and services rendered to the patient during the current visit?

Which is the financial record source document used by health care providers and other personnel in a hospital outpatient setting to select codes for treated diagnoses and services rendered to the patient during the current visit?

Which is a manual permanent record of all financial transactions between the patient and the practice?

Which is a computerized permanent record of all financial transactions between the patient and the practice?

The manual daily accounts receivable journal is also known as the __________, and it is a chronologic summary of all transactions posted to individual patient ledgers/accounts on a specific date.

Which is the electronic or manual transmission of claims data to payers or clearinghouses for processing?

A clearinghouse that involves value-added vendors, such as banks, in the processing of claims is called a value-added __________ to improve efficiency and reduce expenses.

When selecting a clearinghouse, providers may also want to determine whether it is accredited by the __________.

Clearinghouses process claims in an electronic flat file format, which requires conversion of CMS-1500 claims data to a standard format. Providers can also use software to convert claims to an electronic flat file format, also known as a(n) __________, which is a series of fixed-length records (e.g., 25 spaces for patient's name) submitted to payers as a bill for health care services.

The computer-to-computer transfer of data between providers and third-party payers (or providers and health care clearinghouses) in a data format agreed upon by sending and receiving parties is called electronic __________.

Which is an electronic format supported for health care claims transactions?

Covered entities are required to use mandated national standards when conducting any of the defined transactions covered under HIPAA. Which is an example of a covered entity?

Electronic claims are submitted directly to the payer after being checked for accuracy by billing software or a health care clearinghouse, which results in a __________ claim that contains all required data elements needed to process and pay the claim.

A claims attachment is __________ documentation associated with a health care claim or patient encounter.

Coordination of benefits (COB) is a provision in __________ health insurance policies intended to keep multiple insurers from paying benefits covered by other policies.

Which involves sorting claims upon submission to collect and verify information about the patient and provider?

Which involves comparing the claim to payer edits and the patient's health plan benefits to verify that the required information is available to process the claim, the claim is not a duplicate, payer rules and procedures have been followed, and procedures performed or services provided are covered benefits?

Any procedure or service reported on the claim that is not included on the master benefit list is a noncovered benefit and will result in claims __________.

Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization, are called __________ services.

The claim is also checked against the __________, which is an abstract of all recent claims filed on each patient and helps determine whether the patient is receiving concurrent care for the same condition by more than one provider.

Claims adjudication involves making a determination about __________ charges, which is the maximum amount the payer will permit for each procedure or service, according to the patient's policy.

Which is the total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits?

A policyholder or __________ is the person in whose name the insurance policy is issued.

Which is the percentage the patient pays for covered services after the deductible has been met and the copayment has been paid?

Which is the fixed amount the patient pays each time he or she receives health care services?

Sally Simmons is a patient of Dr. Tyler's. She received preventive services for her annual physical examination on May 17. The third-party payer determined the allowed charge for preventive services to be $100, for which the payer reimbursed the physician 80 percent of that amount. Sally is responsible for paying the remaining 20 percent directly to the physician. Thus, the physician will receive a check in the amount of __________ from the payer, and the patient will pay __________ to the physician.

The patient underwent office surgery on March 18, and the third-party payer determined the allowed charge to be $1,480. The patient paid the 20 percent coinsurance at the time of the office surgery. The physician and patient each received a check for $1,184, and the patient signed her check over to the physician. The overpayment was __________, and the physician must reimburse the third-party payer.

A remittance advice submitted to the provider electronically is called an electronic remittance advice (ERA), and __________.

Medicare calls its remittance advice a(n) __________.

Providers have the option of arranging for __________, which means that payers deposit reimbursement for health care services to the provider's account electronically.

Which is considered a financial source document from which an insurance claim is generated?

Which claims are organized by month and insurance company after submission to the payer, but for which processing is not complete?

Which claims are filed according to year and insurance company and include those for which all processing, including appeals, has been completed?

Which claims are organized by year and are generated for providers who do not accept assignment?

An appeal is documented as a(n) __________ why a claim should be reconsidered for payment.

A pre-existing condition is any medical condition that was diagnosed and/or treated within a specified period of time __________ the enrollee's effective date of coverage.

Which are the amounts owed to a business for services or goods provided?

Which requires providers to make certain written disclosures concerning all finance charges and related aspects of credit transactions (including disclosing finance charges expressed as an annual percentage rate)?

Which establishes the rights, liabilities, and responsibilities of participants in electronic fund transfer systems?

Which prohibits discrimination on the basis of race, color, religion, national origin, sex, marital status, age, receipt of public assistance, or good-faith exercise of any rights under the Consumer Credit Protection Act?

Which amended the Truth in Lending Act and requires credit and charge card issuers to provide certain disclosures in direct mail, telephone, and other applications and solicitations for open-ended credit and charge accounts and under other circumstances?

Which amended the Truth in Lending Act and requires prompt written acknowledgment of consumer billing complaints and investigation of billing errors by creditors?

Which protects information collected by consumer reporting agencies such as credit bureaus, medical information companies, and tenant screening services?

Which states that third-party debt collectors are prohibited from employing deceptive or abusive conduct in the collection of consumer debts incurred for personal, family, or household purposes?

A delinquent account is also called a __________ account, which means it is one that has not been paid within a certain time frame (e.g., 120 days). Following up on such delinquent accounts is crucial to the success of the business.

The delinquent claim cycle advances through aging periods, and providers typically focus __________ recovery efforts for older delinquent claims.

Which is the assignment of lower-level codes than documented in the record?

Which is the practice of submitting multiple CPT codes when just one code should have been submitted?

One reason to track unpaid claims is due to the payment error in which a patient erroneously cashes a check made out to both patient and provider, which is called a __________.

When dealing with delinquent claims, it is important to review records to determine whether the claim was paid, was denied, or is pending. A pending claim is considered in __________.

Many physician practices contract out or __________ the delinquent accounts to a full-service collections agency that utilizes collection tactics, including written contacts and multiple calls from professional collectors.

An account receivable that cannot be collected by the provider or a collection agency is called a bad debt. To deduct a bad debt, the amount must have been __________.

Which is a legal action that can be used to recover a debt and is usually a last resort for a medical practice?