Study Guide 30-31

Question 1

What is the name of the Universal claim form?

Answer 1

-CMS-1500 Health Insurance Claim Form?

Question 2

What are some reasons that a claim would be rejected?

Answer 2

If it contains invalid, mismatched procedures or missing data elements required for acceptance , it is considered an unclean, dirty claim.

Question 3

What is the purpose of the bank statement/bank reconciliation?

Answer 3

Bank statement reconciliation is used as an audit to ensure that the bank is managing funds in the account accurately and no fraud has occurred. It helps locate any error

Question 4

What is an Incomplete claim

Answer 4

a claim which, if properly corrected to completion, may be compensable for the covered procedure, but lacks important or material elements which prevent payment of the claim.

Question 5

What is a clearinghouse and their job is?

Answer 5

A clearing house is a financial institution formed to facilitate the exchange of payments, securities, or derivatives transactions. The clearing house stands between two clearing firms. Its purpose is to reduce the risk of a member firm failing to honor its trade settlement obligations.

Question 6

What is an EOB and what information is found in it?

Answer 6

A document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, and the patient’s financial responsibilities
EOB contains patient and provider information,date of service,amount billed by the provider,copayment, provider fee adjustment,deductible, coinsurance
Explanation of benefits

Question 7

The Federal Tax ID number (Box 25) for the provider filing the claim can be presented as a

Answer 7

SSN (social security number) or EIN (employee identification number)

Question 8

What is an Assignment of benefits:

Answer 8

an agreement that transfers the insurance claims rights or benefits of the policy to a third party

Question 9

What are the 3 sections of the CMS 1500 form and what information is found in them-

Answer 9

Section 1: Carrier: type of insurance
Section 2: Patient and Insured information
Section 3: Physician or Supplier information

Question 10

What is Par?

Answer 10

Participating provider

Question 11

On the CMS 1500 in which section would you find information about the insured and the patient?

Answer 11

Section 2

Question 12

Who is CMS

Answer 12

Centers for Medicare and Medicaid Services

Question 13

The providers NPI goes into which block on the CMS 1500 form

Answer 13

Section 3, block 17b

Question 14

How many diagnoses can be placed on CMS 1500 form

Answer 14

12

Question 15

The insured’s address in block 7 refers to the __________ address

Answer 15

Permanent

Question 16

The patient’s name is found in block of the CMS 1500 form

Answer 16

Block 2

Question 17

What is Fraud and abuse?

Answer 17

Fraud is defined as knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare benefit program or to obtain by means of false pretenses or promise any of the money or property owned by any healthcare benefit program. Abuse is an unintended action that directly or indirectly results in overpayment to the healthcare provider

Question 18

How often should checks be deposited?

Answer 18

Daily

Question 19

The physician’s office place-of-service code is found in the —–of the CMS 1500

Answer 19

24b

Question 20

What is the date found in Block 14?

Answer 20

Date of current illness, injury, or pregnancy (LMP)

Question 21

The physician’s signature is located in block of the CMS 1500

Answer 21

(31)

Question 22

In what block does the CPT codes go?

Answer 22

Block 24D

Question 23

The assignment of benefits is located in a block of the CMS 1500?

Answer 23

27

Question 24

The patient’s name is found in block of the CMS 1500 form

Answer 24

Block 2

Question 25

Block 1 of the CMS-1500 contains what information?

Answer 25

Shows type of insurance the patient has

Question 26

Accounts payable

Answer 26

money owed by a company to other companies for services and goods; pertains to paying the facility’s bills

Question 27

Secondary Insurance Information goes into which Block on the CMS 1500

Answer 27

Section 2: 9a-d

Question 28

Accounts receivable

Answer 28

the money owed to the business that has not yet been received

Question 29

What are the things the medical office should consider when selecting a collection agency

Answer 29

the collection agency represents the healthcare facility and they should make sure that the patients are treated with as much respect and dignity as possible throughout the collection process ??

Question 30

Why would the medical office consider taking a patient to small claims court?-

Answer 30

State laws place a limit on the amount of debt for which relief may be sought in small claims court

a local court in which claims for small sums of money can be heard and decided quickly and cheaply, without legal representation.

Question 31

What are some ways the medical office can collect outstanding bills from patients?

Answer 31

collection phone calls, collection letters, emails, and text messages

Question 32

Who is financially responsible for a minor seeking treatment for STD without parental consent?

Answer 32

The parent should be financially responsible unless they are legally emancipated

Question 33

Know the types of payment arrangements that fall under the TILA

Answer 33

monthly payment plan which allows the patient to make more than 4 monthly payments

Question 34

What is the Birthday rule and how does it work with the parents having 2 Insurances?

Answer 34

The birthday rule is whichever parents birth date falls first in the calendar year is considered to have the primary insurance. The year is not used. So if the mothers birthday is Feb 20th and the dad’s birthday is May 1st the mom has the primary and is billed first and if there’s remaining balance it is billed to the secondary insurance which is the dads.

Question 35

What is the National Provider Identifier and is it assigned by the AMA.

Answer 35

An identifier assigned by the CMS that classifies the healthcare provider by license and medical specialties
The NPI number

Question 36

When should the patient’s information, demographics and Insurance information be collected?

Answer 36

New patients when they make their first appointment and at the time of arrival, Patient Information Form. For established patients it should be verified upon arrival

Question 37

The first step in filing a claim with a third-party is

Answer 37

CMS-1500 as the the standard claim form/ indicate the type of insurance and plan of the patient??

know the at-fault driver’s name, auto insurance policy number, phone number, and details about the accident

Question 38

If the ICD-10-CM codes and the CPT/HCPCS codes do not match the claim will not show ________.

Answer 38

Medical necesity

Question 39

What steps should be followed before rendering services to the patient?

Answer 39

Collect patient information, copy insurance card, verify, precertification, and collect copayment

Question 40

What are the steps to obtain preauthorization?

Answer 40

• The medical assistant starts the process by contacting the insurance company’s provider services. The contact information is usually on the back of the patients health insurance card.
• The MA will need to provide the insurance company with the diagnostic and procedure codes for the procedure and/or services and the diagnosis
• If medical documentation is required, the medical assistant will need to submit the required information
• The medical assistant needs to document the contact with the insurance company in the patient health record, including any additional information from the insurance company

Question 41

What are the methods to verify Insurance eligibility of a patient

Answer 41

MA should collect insurance information at the time of scheduling and verifying the patient is covered, can call the insurance provider or check the online insurance web portal to verify the eligibility of the patient and the effective date

Question 42

When are Claims that are done by direct billing first go to a clearinghouse

Answer 42

they are forwarded to the individuals insurance carrier