Ch 15: Review Test Flashcards
Keys to Successful Claims Management
When does the claims process begin?
When the patient first contacts the office for an appointment
In most cases, the health insurance professional should reverify patient information how often?
At least once a year
In the case of a minor child of a divorced couple who is covered under both parents’ group healthcare plans, the health insurance professional should do what?
Determine which carrier is primary
Many medical practices include a section (often positioned at the bottom of the form) for the patient to sign an ____
Authorization to release information
Services that typically require preuthorization or precertification include what?
Inpatient hospitalization
After a paper claim is completed, to help reduce claims rejection and delay, it is a good practice FIRST to have the claim ____
Proofread
What is the most important process in the healthcare insurance cycle?
Submitting a clean claim
What number is assigned by the Internal Revenue Service (IRS) and used as the employer identifier standard for all electronic healthcare transactions?
Employer identification number (EIN)
After the claim has been received by a third-party payer, it is reviewed, and the carrier makes payment decisions. This process if formally referred to as what?
Adjudication
When the insurance carrier receives a paper claim, it is dated and the claim is processed through a(n) ____
Optical character recognition (OCR) scanner
A series of files set up chronologically and labeled according to the number of days since a claim was submitted is commonly referred to as what?
Suspension file
A columnar form on which insurance claims are tracked is a(n) ____
Insurance claims register
The document sent by the insurance carrier to the provider and patient explaining how the claim was adjudicated is called what?
Explanation of Benefits
The key to knowing how much of the claim was paid, how much was not, ans why is documented on the ____
EOB
When a carrier assigns a substitute code because a claim was submitted with outdated, deleted, or nonexistent CPT codes, it is called what?
Downcoding
Ideally, insurance claims should be submitted to the insurance carrier within how many days?
30 days
If there is any question as to time limits for filing claims, the health insurance professional should contact who?
The carrier
The insurance company that pays after the primary carrier is referred to as the ____
Secondary insurer
In the case of dual coverage, if it is not immediately obvious which payer is primary, the health insurance professional should first ask who?
The patient
Complete fields 9, 9a, and 9d on the CMS-1500 claim form is “YES” appears in ____
Block 11d
If a patient and spouse (or parent) are covered under two separate group policies, it results in what is commonly referred to as what?
Coordination of Benefits
Claims that are submitted to another insurance company BEFORE they are submitted to Medicare are called what?
Medicare Secondary Payer claims
The process of calling for a review of a decision made by a third-party carrier is referred to as a(n) ____
Appeal
The Medicare appeal process has ____ levels?
Five
The health insurance professional should be familiar with the CMS-1500 paper claim process because ____
Not all providers submit claims electronically
