Billing Rules
Medical insurance specialists rely on which of the following to stay up to date with payers billing rules?
a) bulletins
b) websites
c) regular communications
d) all of these
What is All of these?
A payer's automated claim edits may result in claim denial because of
a) lack of eligibility for a reported service
b) lack of medical necessity
c) lack of required preauthorization
d) any of these
What is Any of these?
A typical aging report groups payments that are due into which of these categories?
a) 0–30 days, 31–60 days, 61–90 days, and over 90 days.
b) 0–60 days, 61–120 days, 121–180 days, over 180 days
c) 0–15 days, 16–30 days, 31–45 days, 45–60 days
d) 0–45 days, 46–90 days, 91–135 days, over 135 days
What is 0–30 days, 31–60 days, 61–90 days, and over 90 days?
If a provider has accepted assignment, the payer sends the RA to:
a) the provider
b) the patient
c) the billing service
d) the carrier
What is The Provider?
Under RBRVS, the nationally uniform relative value is based on:
a) the geographic adjustment factor
b) the uniform conversion factor
c) the provider's work, practice cost, and malpractice insurance costs
d) the UCR, practice cost, and malpractice insurance costs
What is The provider's work, practice cost, and malpractice insurance costs?
The CMS/AMA Documentation Guidelines set up the rules for the selection of:
a) Evaluation and Management codes
b) Anesthesia codes
c) Surgery codes
d) Pathology and Laboratory codes
What are Evaluation and Management codes?
A claim that is removed from a payer's automated processing system is sent for
a) adjudication
b) manual review
c) utilization review
d) none of these are correct
What is Manual Review?
Many state and federal laws prohibit which of the following?
a) Audits
b) Adjustments
c) Edits
d) Professional courtesy
What is Professional courtesy?
Remittance advice remark codes explain:
a) adjustments to claims paid on an RA
b) concurrent care that was given
c) denials from claims
d) insurance aging report
What are Adjustments to claims paid on an RA?
If a patient has additional insurance coverage, after the primary payer's RA has been posted, the next step is:
a) waiting until the patient pays
b) determining what the write off amount is
c) billing the second payer
d) waiting until the primary insurance bills the second payer
What is Billing the second payer?
If a payer judges that too high a code level has been assigned by a practice for a reported service, the usual action is to:
a) deny the claim
b) downcode the reported procedure code
c) upcode the reported procedure code
d) add a modifier to the reported procedure code
What is Downcode the reported procedure code?
What is the correct order for the basic steps of a payer's adjudication process?
a) automated review, initial processing, manual review, determination, and payment.
b) initial processing, automated review, manual review, determination, and payment.
c) initial processing, manual review, automated review determination, and payment.
d) manual review initial processing, automated review, determination, and payment.
What is Initial processing, automated review, manual review, determination, and payment?
If balance billing is permitted under a plan, the insured must:
a) Pay for the entire provider's charge
b) Pay for only his/her deductible
c) Pay for the difference between the provider's charge and the allowed charge
d) Pay nothing since it is part of the contractual agreement
What is Pay for the difference between the provider's charge and the allowed charge?
A paper explanation of benefits (EOB) is sent to patients by payers after claims:
a) are paid
b) are denied
c) are submitted
d) are received
Which of the following is not fraudulent?
a) Altering documentation after services are reported
b) Coding without proper documentation
c) Reporting services provided by unlicensed personnel
d) Using a non-specific diagnosis code
What is Using a non-specific diagnosis code?
Routinely waiving deductibles and copayments is:
a) legal
b) illegal
c) common practice
d) okay for Medicare patients only
What is Illegal?
A payer's determination means it is going to:
a) suspend the claim
b) pay, deny, or partially pay the claim
c) review the claim
d) none of these are correct
What is Pay, deny, or partially pay the claim?
If a practice accepts credit and debit cards it must follow which standard?
a) HIPAA
b) HITECH
c) FERPA
d) PCI DSS
What is PCI DSS?
The abbreviation MRN stands for:
a) Medicare Reinstatement Notice
b) Medicare Reconciliation Notice
c) Medicare Rejection Notice
d) Medicare Redetermination Notice
What is Medicare Redetermination Notice?
Which of the following is considered a formal examination?
a) Audit
b) Adjustment
c) Edits
d) Professional courtesy
What is Audit?
The unit of service (UOS) edits that CMS uses are called:
a) medically unlikely edits (MUEs)
b) Correct Coding Initiative (CCIs)
c) Recovery Audit Contractors (RACs)
d) geographic practice cost index (GPCI)
What are medically unlikely edits (MUEs)?
If the provider has not accepted assignment, the payer sends the payment to:
a) the provider
b) the patient
c) the billing service
d) the carrier
What is The patient?
PMP is the abbreviation for:
a) Physician management program
b) Practice management program
c) Physician medical program
d) Practice medical program
What is Practice management program?
When a payer's RA is received, the medical insurance specialist:
a) checks that the amount paid matches the expected payments
b) deposits that payment into the patient's bank account
c) sends the patient a refund of what the patient already paid
d) does nothing, as these services are all computerized
What is Checks that the amount paid matches the expected payments?
Minor errors found by the practice on transmitted claims require which of the following:
a) a completely new claim to be filed
b) corrections by asking the payer to reopen the claim and make the changes
c) corrections by asking the payer to adjust the charges
d) a denial
What is Corrections by asking the payer to reopen the claim and make the changes?