Ch 15: True and False

Question 1

T/F: Ultimately, it is the patient’s responsibility to know when and how to notify the insurance company for preauthorization or precertification

Answer 1

True

Question 2

T/F: Medicare (fee-for-service) does not need prior authorization to provide covered services

Answer 2

True

Question 3

T/F: It is the health insurance professional’s responsibility to document appropriate comments in the patient’s medical record that pertain to his or her health

Answer 3

False

Question 4

T/F: One of the main changes in the revised CMS-1500 (02/12) claim form is the expansion from 4 diagnostic codes to 12 in Block 21

Answer 4

True

Question 5

T/F: All major government payers have the same guidelines for completing the CMS-1500 claim form

Answer 5

False

Question 6

T/F: The medical practice should have a mechanism in place for tracking claims

Answer 6

True

Question 7

T/F: Claims follow-up does not warrant high priority in a busy medical office

Answer 7

False

Question 8

T/F: When dealing with Medicare and Medicaid, claims inquiries must be in writing

Answer 8

True

Question 9

T/F: The third-party payer sends an EOB only if a payment accompanies the document

Answer 9

False

Question 10

T/F: EOBs can be in electronic or paper format

Answer 10

True

Question 11

T/F: When an insurance claim is denied, the health insurance professional cannot pursue the claim further

Answer 11

False

Question 12

T/F: Often, if a claim is reduced or rejected, the problem lies with the provider’s office

Answer 12

True

Question 13

T/F: Coding accurately and knowing which coding systems payers use help avoid payment errors on claims

Answer 13

True

Question 14

T/F: If the claims adjuster changes a valid procedure code that was submitted on the claim, the health insurance professional must accept the change

Answer 14

False

Question 15

T/F: Correct code initiative edits are intended to reduce overpayments that result from improper coding

Answer 15

True

Question 16

T/F: All participating (PAR) providers are allowed to bill the patient for any balance the insurance carrier does not pay

Answer 16

False

Question 17

T/F: The provider cannot waive Medicare co-payments unless financial hardship has been established and documented

Answer 17

True

Question 18

T/F: All third-party payers have a 30-day time limit for claims to be submitted if they are to be considered for payment

Answer 18

False

Question 19

T/F: Government payers usually will pay a claim even if the time limit for claim submission has been exceeded

Answer 19

False

Question 20

T/F: The time limit for filing appeals varies from carrier to carrier

Answer 20

True

Question 21

T/F: When a patient has other insurance coverage primary to Medicare, the other insurer’s payment information must be included on the Medicare claim

Answer 21

True

Question 22

T/F: The total amount of money collected divided by the total amount charged is referred to as the collection ratio

Answer 22

True

Question 23

T/F: HIPAA requires all payers to use the applicable healthcare claims status category codes and claim status codes

Answer 23

True

Question 24

T/F: One way of optimizing the billing and claims process is to ask patients to wait to pay until they receive a statement in the mail

Answer 24

False

Question 25

T/F: If all efforts of appeal are exhausted without success, a remaining option is to contact the state insurance commissioner’s office

Answer 25

True