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Door #1
Door #2
Door #3
Door #4
Door #5
100
The 14,000 ICD-9-CM codes are categorized by the DRG system into ________ major diagnostic categories (MDCs)
What is 25
100
What is NOT a type of HMO
What is Gatekeeper model
100
When a patient is covered by more than one insurance plan, the ________ plan adjudicates the claim first, followed by the ________ plan.
What is primary; secondary
100
All of the following are categories of hospital acquired conditions (HACs), EXCEPT? (Double Jeopardy)
What is myocardial infarction
100
A delay imposed by Medicare intermediaries and some other health plans in paying claims is called a payment floor (True or False)
What is True
200
A unique ID number assigned by a health plan to each policy is a? (Multiple Answers)
What is policy number, insurance ID, and member number
200
What is a bill for healthcare services or supplies called?
What is a Claim
200
The person responsible for the patient's portion of the bill is the
What is a guarantor
200
What are the two things that the provider receives from the insurance plan (Double Jeopardy)
What is both remittance and reimbursement
200
The referral certification and authorization process can be conducted electronically by using the
What is Health Care Services Request for Review and Response
300
The payment to which a hospital is entitled is calculated by multiplying which of the following
What is The hospital's IPPS rate by the RW of the DRG code
300
The skilled nursing facility (SN~prospective payment system reimbursement rate is based upon what?
What is RUG-III
300
Outpatient Prospective Payment System is used for? (Multiple Answers)
What is partial hospitalization services by community mental health centers, hospital outpatient services, certain Medicare B services provided to hospitalized patients who do not have Medicare A, and administration of certain vaccines, splints, casts, and antigens by home health agencies
300
________ agree not to collect more for a service than the amount allowed by the contract
What is participating providers
300
The ________ is used to send the request for authorization and for the plan to return information about the authorization, certification, or referral to the provider
What is ANSI 278
400
Inpatient acute care hospitals are reimbursed a single total payment for each patient discharge based on a(n) ________ code, which assumes that patients with the same sort of diagnoses require about the same length of stay and use approximately the same amount of resources (Double Jeopardy)
What is DRG
400
An explanation of benefits (EOB is also referred to as a(n)? (Double Jeopardy)
What is a remittance advice
400
Medicare is a health insurance program for? (Multiple Answers)
What is people of any age with kidney failure requiring dialysis or transplant, people 65 and older, and people under the age of 65 who have disabilities
400
A Resource-Based Relative Value Scale for each code is determined using? (Multiple Answers)
What is malpractice expense, practice expense, and physician work
400
The payment floor for paper claims is
What is 29 days
500
The reason (after study) that the patient was admitted to the hospital is called the
What is both principle diagnosis and discharge diagnosis
500
A physician must renew an order for home health care every
What is 60 days
500
A capitation model succeeds when the group of HMO patients is large enough that the costs of treating members who need services and those who never see the doctor average out (True or False)
What is True
500
What refer to records created by abstracting relevant details from the primary records (Double Jeopardy)
What is secondary records
500
When a plan asks for further information, supporting documentation, or test results, the claim becomes a(n)
What is suspended claim