Ch12- BCBS

Question 1

Which of the following defines Point-of-Service coverage?
a. Coverage that requires a patient to first see their PCP
b. Coverage that allows members to choose medical services only within the BCBS network
c. Coverage that allows members to choose medical services as needed within the BCBS network or seek medical care outside of the network
d. Coverage that reimburses employees for specific healthcare expenses

Answer 1

c. Coverage that allows members to choose medical services as needed within the BCBS network or seek medical care outside of the network

Rationale: Point-of-Service (POS) coverage is a healthcare option that allows members to choose medical services as needed, and whether they will go to a provider within the Blue Cross and Blue Shield network or seek medical care outside of the network.

Question 2

An indemnity plan is also referred to as _____________.
a. Fee-for-Service
b. Self-pay
c. Health Savings account
d. Preferred Provider Organization

Answer 2

a. Fee-for-Service

Rationale: An indemnity is a traditional plan or fee-for-service plan.

Question 3

When a provider signs a contract to be a participating provider with an insurance payer they are agreeing to:
a. Only see patients that are enrolled with that insurance company
b. Bill the patient for the total amount the insurance company does not pay
c. Accept the fee schedules set by the insurance company
d. All of the above

Answer 3

c. Accept the fee schedules set by the insurance company

Rationale: Participating providers sign contracts with the insurance companies they wish to participate with and agree to accept the fee schedules set by the insurance company. The physician then can only bill the patient their copay, deductible, co-insurance, or any non- covered services. They cannot balance bill the patient the difference between what the company allowed and what the physician billed.

Question 4

Which of the following is an account that is usually funded by the employee only and reimburses employees for specified expenses as they are incurred?
a. HRA
b. HSA
c. FSA
d. HMO

Answer 4

c. FSA

Rationale: An FSA is an account that reimburses employees for specified expenses as expenses are incurred. The funding for FSAs is usually through deductions from the employee’s paychecks.

Question 5

Which type of insurance plan is a federal and state program that provides coverage to the low-income population?
a. Medicare
b. HMO
c. Medicaid
d. PPO

Answer 5

c. Medicaid

Rationale: Medicaid is a joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

Question 6

Which of the following statements is NOT correct regarding timely filing?
a. Claims must be filed before the end of the timely filing limit.
b. Each BCBS carrier sets their own timely filing limit.
c. If the physician fails to send a claim during the timely filing limit, the balance can be sent to the patient.
d. The timely filing limit can vary from plan to plan within the same insurance company.

Answer 6

c. If the physician fails to send a claim during the timely filing limit, the balance can be sent to the patient.

Rationale: Failure to meet the timely filing limit does not allow for the patient to be billed for this encounter.

Question 7

What is the timely filing requirement for Blue Cross Blue Shield?
a. 90 days
b. 180 days
c. Filed by December31
d. Claim requirements differ between plans

Answer 7

d. Claim requirements differ between plans

Rationale: Claim filing requirements differ between the different Blue Cross/Blue Shield plans. Unless otherwise specified in the contract, the timely filing limit for Blue Cross/Blue Shield plans is one year from date of service.

Question 8

What is the correct action when the three-character prefix is not appended to a BCBS identification number?
a. Append the most common local prefix and file the claim.
b. Append XXX as the prefix and file the claim.
c. Append ZZZ as the prefix and file the claim.
d. Look at the patient’s BCBS card and append the appropriate prefix listed on the card.

Answer 8

d. Look at the patient’s BCBS card and append the appropriate prefix listed on the card.

Rationale: The prefix of the member’s identification number helps identify the BCBS home company and the plan. The insurance card should be viewed so the correct three-character prefix is appended.

Question 9

Which of the following information would NOT be found on an EOB?
I. Claim total
II. Adjustment applied to the submitted claim
III. Amount paid
IV. Patient’s DOB
V. Address of provider
a. I, II, III
b. II, III
c. I, V
d. IV, V

Answer 9

d. IV, V

Rationale: Patient’s DOB (IV) and Address of provider (V), would not be found on the explanation of benefits form. The claim total, adjustment applied to the submitted claim and the amount paid will always be information reported on the EOB.

Question 10

The process of reviewing and validating professional qualifications of healthcare providers applying to participate with an organization is known as:
a. certification.
b. credentialing.
c. endorsement.
d. accreditation.

Answer 10

b. credentialing.

Rationale: Providers who apply for participation with a payer organization must undergo a process of professional qualification review and validation known as credentialing.

Question 11

Balance billing by participating providers is:
a. Not allowed under a participating provider’s contract.
b. Necessary for maintaining a profitable practice.
c. Common practice among participating providers.
d. Allowed only when the amount billed by the physician is greater than 20% of the contract amount.

Answer 11

a. Not allowed under a participating provider’s contract.

Rationale: Participating providers sign contracts with the insurance companies they wish to participate with and agree to accept the fee schedules set by the insurance company. The physician then can only bill the patient their copay, deductible, co-insurance., and any non-covered services They cannot balance bill the patient the difference between what the company allowed and what the physician billed.

Question 12

A claim is submitted for a patient who suffered a fractured femur. The diagnosis code that was submitted is S82.401A, with the CPT® fracture care code 27230. Does the diagnosis code support medical necessity for the service provided?
a. Yes, the diagnosis code supports the CPT® code billed.
b. No, the diagnosis code does not support the CPT® fracture care code.
c. A diagnosis code is not necessary when reporting CPT® codes.
d. Yes, the procedure code is supported by the ICD-10-CM code.

Answer 12

b. No, the diagnosis code does not support the CPT® fracture care code.

Rationale: Medical necessity was not met because the diagnosis code reports a fracture of the fibula, and the CPT® code reports a fracture of the femur. When a diagnosis is not submitted correctly, the information needs to be corrected and the corrected claim resubmitted.

Question 13

Jared is employed with the United States Internal Revenue Service and has enrolled in the Blue Cross/Blue Shield healthcare insurance offered through this employer. What is the name of the Blue Cross/Blue Shield insurance program offered by the federal government?
a. GEP (Government Employee Program)
b. FEP (Federal Employee Program)
c. FWP (Federal Worker Program)
d. FIP (Federal Insurance Program)

Answer 13

b. FEP (Federal Employee Program)

Rationale: The BC/BS Federal Employee Program (FEP) covers more than 5.6 million federal government employees, dependents, and retirees.

Question 14

A patient seeks care from a neurologist without a referral from the patient’s primary care physician, which is required by the insurance company. What is the likely outcome for neurologist’s claim?
a. The claim will be paid at full rate.
b. The claim will be paid at a 75% of fee.
c. The claim will be paid at 50% of fee.
d. The claim will be denied.

Answer 14

d. The claim will be denied.

Rationale: Some insurance plans require a referral from a PCP (Primary Care Physician) for a patient to receive care from a specialist. If the patient or provider fails to receive a referral from the PCP, the claim can be denied.

Question 15

A savings account that allows individuals to save pre-tax dollars to reimburse for healthcare expenses is known as a(n):
a. Flexible Spending Account (FSA)
b. Health Savings Account (HSA)
c. Employer Savings Account (ESA)
d. Both a and b

Answer 15

d. Both a and b

Rationale: Flexible Spending or Health Savings Accounts allow individuals to set aside pre-tax dollars to build savings which can be used to reimburse the insured for healthcare related expenses. Contributions can be made through payroll deductions and/or employer contributions.

Question 16

The best practice to prevent a non-covered service denial would be to:
a. determine what documentation is needed to report the service.
b. determine if the procedure is covered prior to providing the service.
c. notify the patient of the risks and benefits of the procedure.
d. ensure that the procedure or service is performed correctly.

Answer 16

b. determine if the procedure is covered prior to providing the service.

Rationale: A claim can be denied by the insurance payer if the service is not covered under the insurance plan. To prevent these denials, determine if the procedure is covered prior to the service being provided.

Question 17

The Blue Cross/Blue Shield member’s insurance card will list which of the following:
a. Date of birth of the member
b. Type of insurance
c. Type of plan
d. Both b and c

Answer 17

d. Both b and c

Rationale: At the top of the card the type of insurance with the type of plan (such as PPO, HMO, POS, traditional, etc.) is listed.

Question 18

Participating providers agree to:
a. only treat established patients.
b. only treat patients with chronic conditions.
c. accept the fee schedules determined by the insurance company.
d. only treat patients who have insurance coverage.

Answer 18

c. accept the fee schedules determined by the insurance company.

Rationale: Participating providers sign contracts with the insurance companies they wish to participate with and agree to accept the fee schedules set by the insurance company.

Question 19

Obtaining approval from the insurance payer before a procedure is performed is known as:
a. prior authorization.
b. signing a contract.
c. initial approval.
d. initial authorization.

Answer 19

a. prior authorization.

Rationale: A prior authorization is required by insurance plans for many procedures. If the plan requires a prior authorization before receiving services and the provider fails to obtain one the claim can be denied.

Question 20

What information can be found on the Blue Cross/Blue Shield insurance identification card?
I. Type of plan
II. Subscriber’s address and phone number
III. ID number
IV. Group number
V. Name of primary care provider
VI. Phone number for Member Services/Benefits questions
VII. Mailing address of BC/BS office
a. I, III, IV, VI, VII
b. V, VI, VII
c. II, V, VII
d. I, III, IV, VI

Answer 20

a. I, III, IV, VI, VII

Rationale: The type of plan, ID number, group number, phone numbers and mailing address of BC/BS office for submission of paper claims are some of the information found on the insurance ID card. Additional information such as prescription, co-pay and deductible amount can also be referenced on the card.

Question 21

A patient’s insurance member card is issued by:
a. the insurance company.
b. the state.
c. the physician’s office.
d. the employer.

Answer 21

a. the insurance company.

Rationale: A Member Card is a card that the insurance company issues to each member to carry for identification.

Question 22

Tony’s Blue Cross/Blue Shield healthcare insurance policy states that he must seek healthcare services only from providers that are part of a specific network. What type of Blue Cross/Blue Shield plan does Tony have?
a. POS
b. HMO
c. Fee-for-Service
d. Indemnity

Answer 22

b. HMO

Rationale: An HMO is a type of health benefits plan where members are required to receive healthcare services only from providers that are part of the HMO network.

Question 23

Best practice to prevent receiving a denial due to coverage termination would be to:
a. call each payer every month to ensure that each scheduled patient is still covered.
b. verify coverage after the patient is seen by provider.
c. verify coverage prior to the patient’s scheduled appointment.
d. contact each patient every month to verify insurance coverage.

Answer 23

c. verify coverage prior to the patient’s scheduled appointment.

Rationale: A coverage termination denial occurs when the patient does not have coverage with the insurance payer. To prevent these types of denials it is important to verify coverage prior to the scheduled visit. Many payers have internet-based, self-service portals where this can be verified.

Question 24

The term for the set payment that the member pays to the healthcare provider on the day of service is the:
a. co-signer.
b. copay.
c. coinsurance.
d. office visit fee.

Answer 24

b. copay

Rationale: A copayment or copay is the set amount the insured member pays the healthcare provider on the day of service.

Question 25

Blue Cross/Blue Shield identifies the individual or employee who pays for healthcare insurance coverage as the:
a. payer
b. member
c. group
d. subscriber

Answer 25

d. subscriber

Rationale: The subscriber (policyholder) is the person who pays for the health insurance or whose employment makes him or her eligible for group health insurance.

Question 26

The liaison between Blue Cross/Blue Shield and the contracted provider community is known as the:
a. insurance Representative.
b. provider Representative.
c. provider Network Consultant.
d. All of the above.

Answer 26

d. All of the above.

Rationale: An Insurance Representative, also called a Provider Representative or Provider Network Consultant serves as the liaison between Blue Cross and Blue Shield and the contracted provider community.

Question 27

Timely filing requirements are:
a. Unimportant
b. Determined by the payer
c. Always 1 year from the date of service
d. 30 days from date of service

Answer 27

b. Determined by the payer

Rationale: Each insurance company sets their own timely filing limits. It can also vary by different insurance plans within the same company.

Question 28

Blue Cross and Blue Shield is the:
a. oldest and smallest family of health benefits companies in the United States.
b. oldest and largest family of health benefits companies in the United States.
c. newest and largest family of health benefits companies in the United States.
d. only health insurance company promoting preferred provider organizations.

Answer 28

b. oldest and largest family of health benefits companies in the United States.

Rationale: Blue Cross and Blue Shield companies are the nation’s oldest and largest family of health benefits companies. Nationwide, more than 1.7 million doctors and hospitals contract with Blue Cross Blue Shield companies — more than any other insurer.

Question 29

When a patient presents for their appointment, insurance coverage should be verified and:
a. a copy made of the back of the insurance card.
b. a copy made of their driver’s license or other form of ID.
c. a copy made of both the front and back of the member’s insurance card.
d. a copy made of the front of the insurance card.

Answer 29

c. a copy made of both the front and back of the member’s insurance card.

Rationale: Obtaining a copy of an insurance card, front and back, is imperative. If the information is entered into the practice management system incorrectly or additional information is needed, it can be found on the insurance card.

Question 30

Blue Cross/Blue Shield received a claim on 4/15/21 for services performed on 3/15/20. The claim would be denied because:
a. service did not meet medical necessity.
b. service was not a covered benefit.
c. claim was filed after timely filing limit.
d. the claim did not have correct provider number.

Answer 30

c. claim was filed after timely filing limit.

Rationale: Timely filing limit for Blue Cross/Blue Shield is typically one year from date of service.

Question 31

Developing a strong relationship with the insurance Provider Representative will result in:
a. difficulty resolving claim payment issues.
b. problems with provider credentialing.
c. increased ability to resolve billing, contracting issues that may arise.
d. both a & b

Answer 31

c. increased ability to resolve billing, contracting issues that may arise.

Rationale: Forming a good relationship with the insurance Provider Representative has many benefits. They can assist a provider if they are having billing issues, contracting issues, etc.