Ch 15: Review Test

Question 1

When does the claims process begin?

Answer 1

When the patient first contacts the office for an appointment

Question 2

In most cases, the health insurance professional should reverify patient information how often?

Answer 2

At least once a year

Question 3

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?

Answer 3

Determine which carrier is primary

Question 4

Many medical practices include a section (often positioned at the bottom of the form) for the patient to sign an ____

Answer 4

Authorization to release information

Question 5

Services that typically require preuthorization or precertification include what?

Answer 5

Inpatient hospitalization

Question 6

After a paper claim is completed, to help reduce claims rejection and delay, it is a good practice FIRST to have the claim ____

Answer 6

Proofread

Question 7

What is the most important process in the healthcare insurance cycle?

Answer 7

Submitting a clean claim

Question 8

What number is assigned by the Internal Revenue Service (IRS) and used as the employer identifier standard for all electronic healthcare transactions?

Answer 8

Employer identification number (EIN)

Question 9

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?

Answer 9

Adjudication

Question 10

When the insurance carrier receives a paper claim, it is dated and the claim is processed through a(n) ____

Answer 10

Optical character recognition (OCR) scanner

Question 11

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?

Answer 11

Suspension file

Question 12

A columnar form on which insurance claims are tracked is a(n) ____

Answer 12

Insurance claims register

Question 13

The document sent by the insurance carrier to the provider and patient explaining how the claim was adjudicated is called what?

Answer 13

Explanation of Benefits

Question 14

The key to knowing how much of the claim was paid, how much was not, ans why is documented on the ____

Answer 14

EOB

Question 15

When a carrier assigns a substitute code because a claim was submitted with outdated, deleted, or nonexistent CPT codes, it is called what?

Answer 15

Downcoding

Question 16

Ideally, insurance claims should be submitted to the insurance carrier within how many days?

Answer 16

30 days

Question 17

If there is any question as to time limits for filing claims, the health insurance professional should contact who?

Answer 17

The carrier

Question 18

The insurance company that pays after the primary carrier is referred to as the ____

Answer 18

Secondary insurer

Question 19

In the case of dual coverage, if it is not immediately obvious which payer is primary, the health insurance professional should first ask who?

Answer 19

The patient

Question 20

Complete fields 9, 9a, and 9d on the CMS-1500 claim form is “YES” appears in ____

Answer 20

Block 11d

Question 21

If a patient and spouse (or parent) are covered under two separate group policies, it results in what is commonly referred to as what?

Answer 21

Coordination of Benefits

Question 22

Claims that are submitted to another insurance company BEFORE they are submitted to Medicare are called what?

Answer 22

Medicare Secondary Payer claims

Question 23

The process of calling for a review of a decision made by a third-party carrier is referred to as a(n) ____

Answer 23

Appeal

Question 24

The Medicare appeal process has ____ levels?

Answer 24

Five

Question 25

The health insurance professional should be familiar with the CMS-1500 paper claim process because ____

Answer 25

Not all providers submit claims electronically