Test your basic knowledge |

Medical Billing Claims Basics

Instructions:
  • Answer 50 questions in 15 minutes.
  • If you are not ready to take this test, you can study here.
  • Match each statement with the correct term.
  • Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.
1. Defined by Medicare as 'The determination that a service or procedure rendered is resonable and necessary for the diagnosis or treatment of an illness or injury'






2. When two companies work together to decided payment of benefits






3. Process of assesing medical services to assure medical necessity and the appropriateness of treatment






4. Private health insurance company or employer-based group insurance plan that pays claims for eligible participants






5. Request or message to remind a patient that the account is over due or delinquent






6. Conditions - situations - and services not covered by the insurance carrier






7. Established proce set by a medical practice for proefessional services






8. Means to report the number of times a service was provided on the same date of service to the same patient






9. Listing of diagnosis - procedures - and charges for a patients visit






10. Procedure or services provided without proper authorizationor was not covered by a current authorization -denied - provider can't bill patient for charges






11. Federal Employees' Compensation Act






12. Procedure codes match the diagnosis codes -procedure are not elective -procedures are not exprimental -procedures are essentail for treatment -procedures are furnished at a appropriate level






13. Company that translates electroinc transactions between the standard formats and code set required under HIPAA and nonstandard formats and code sets






14. Any procedure or service reported on insurance claim that is not listed in payer's master benefit list -results in denial -payers may be able tp recover charges






15. Amount required by an insurance company that must be taken off a patient's acoount based on actual agreements and participation






16. Money amount determined by dividing the actual charge of a service or procedure by a relative unit






17. Once claim is approved for payment Remittance Advice(RA) is sent to the provider and EOB is mailed to the policyholder






18. A report to track claim status of patient accounts and to identify individual accounts requiring additional workup for payments or write-offs






19. Accounts that are subject to charges from time to time






20. Established proce set by a medical practice for proefessional services






21. Combing lesser services with a major service in order for one charge to include that variety of service






22. Private health insurance company or employer-based group insurance plan that pays claims for eligible participants






23. Alternative to paper claims submitted to the third-party payer directly by the physician or through clearinghouse -paid faster and software has self-editing detects and reports entries may cause to be rejected






24. Procedure or services provided without proper authorizationor was not covered by a current authorization -denied - provider can't bill patient for charges






25. Checking or tracing a claim sent to an insurance comapany to determine payment or processing status






26. Analysis of accounts receivable that indicate delinquency of 60 - 90 - 120 days






27. Entity that recieves transmissions of claims from physicians offices - seperates claims by carriers and performs software edits to check errors -once completed claim is sent to proper insurance -physician pays fee for their services






28. Once claim is approved for payment Remittance Advice(RA) is sent to the provider and EOB is mailed to the policyholder






29. Billing for each item service provided to a patient in accourdance with insurance carriers' policies






30. Agreement between the patoent and the physician regarding monthly installments to pay a bill






31. Durable Medical Equipment Regional Carrier






32. Alternative to paper claims submitted to the third-party payer directly by the physician or through clearinghouse -paid faster and software has self-editing detects and reports entries may cause to be rejected






33. Group 2 or more physicians and non-physicians practitioners legally organized in a partnership - professional corporation - foundation - not-for-profit corporation - faculty pratice plan - or similar assoc






34. Process of looking over a cliam to assess payment amounts






35. Process of looking over a cliam to assess payment amounts






36. Amount charged by a practice when providing services






37. Breaking the account receivable amounts into portions for billing at a specific date of the month






38. Listing service in their order of importance by dates of service and values. Highest charge to lowest charge






39. CMS 1500 - became effective July 2007 -All third party payers accept it - Medicare requires all physicians to use it






40. 1.Collect patients info 2.Verifying Insurance 3.Prepare the encounter form 4.Code the diagnosis and procedures 5.Review linkage and compliance 6.Calculate physicians charges 7.Prepare Claims 8.Transmit claims 9.payer adjudication 10.Follow up on reim






41. Superbill or Encounter Form






42. Deferred or delayed processing method for inputting data a retrieval at a later date






43. Specific time frames assigned to a code by an insurance comapny before additional payment will be made following a surgical procedure






44. Analysis of accounts receivable that indicate delinquency of 60 - 90 - 120 days






45. Percent of payment held back for a risk account in the HMO program






46. Traditional method ised by providers for submissions of charges to insurance companies -CMS 1500 -few plans accept encounter forms Medicare will only acccept CMS 1500`






47. Authorization by a policyholder to allow a thrid-party payer to pay benefits to a health care provider






48. The amount set by the carrier for the reimbursement of services






49. Any procedure or service reported on insurance claim that is not listed in payer's master benefit list -results in denial -payers may be able tp recover charges






50. Fee that is charged for each procedure pr service performed by the physician -fee is obtained from a fee schedule - list of charges or allowance that have accepted for specific medical services