VOB 101
If the patient's remaining OOP is less than the calculated EPR, only quote what?
The remaining OOP.
What are 4 parts of the Medicare and its description?
A - Hospital Insurance - Inpatient, hospice, skilled nursing
B - Medical Insurance - Doctors, outpatient, preventive
C - Medicare Advantage - A + B + extras (private plans)
D - Drug Coverage - Prescription medication
What is the meaning of COB?
Coordination of Benefits
A document from your health insurance company detailing how a medical claim was processed.
EOB / Explanation of Benefits
What is the meaning of HIPAA?
The Health Insurance Portability and Accountability Act.
Where there are 2 EGD Codes on an order, one without biopsy and one with biopsy, which do we choose?
The EGD code with the biopsy
What should a biller do when an encounter has holds other than “Billing – Charge Review” types?
No billing action code yet (do not process account) (NOTHING)
What is the usage of 3528 Alias Code?
Contractual Adj Non Covered
What is the very first thing you need to find in the timeline notes before anything else?
Prior Authorization.
What do we call for claim free of errors that gets processed promptly without delay or rejections.
Clean Claim
Which ENT implants are not covered by insurance?
Latera and Propel
Which action code is used when a claim requires manual submission due to edits or validation issues?
7704 – Work Item Resolution – Manually Submitted Claim or 7704
The first step in processing a patient refund in Cerner is accessing the __________ to locate accounts with self-pay credit balances.
Self-Pay Credit Balance Work Item queue
What other sources of information do you look at aside from calling the payers / carriers?
Payer Portals.
What does the CO-45 remark code indicate?
Charge exceeds fee schedule, Contractual Adjustments
CPT Code 27096 is equal to what other code?
G0260
What action code should be applied when a claim has been reviewed and released to the Integrated Scrubber?
7703 – Work Item Resolution – Worked Claim or 7703
What is the action code will you use to resolve the IWI Adj?
820
A formal request by a policyholder to an insurance company asking for compensation or coverage for a specific loss, damage, or injury covered by their policy.
Claim
What year was USPI founded?
USPI was founded last 1998 with a promise to deliver high-quality, lower-cost solutions in our communities.
A patient has an unmet deductible of $500, an in-network coinsurance rate of 20%, and an out-of-pocket maximum of $5,000. If the total case allowable is $3,000, what is the patient's estimated financial responsibility?
$1,000
What action code is used when a high-dollar claim (over $100,000) needs management review?
7708 – High Dollar Review Needed or 7708
What action Code will you use to Accept the Variance for Bundled CPT?
851
How to Handle Pre-auth denial?
This AR process begins by checking if retro authorization is allowed by the payer, and if not, moves forward with submitting a formal appeal for a denied preauthorization.
When is the USPI Manila launch?
September 01, 2025