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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. 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






2. Using ICD-9 codes to hughest degree






3. Major surgical procedures that typically have a follow-up period of 30 - 60 - 90 - 120 days






4. State based group of physicians working under government guideline to review cases and determine their appropriateness and quality of professional care






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






6. 1. Blocks 1-13=patient info 2.Blocks 14-33=physicians info






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






8. Describes the service billed and includes a breakdown of how payment is determined






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






10. Passed by the federal government to prosecute cases of Medicaid fraud






11. Term for processing payment






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






13. Statement of a patient's account history - showing DOS - detailed chrages - payments - day insurance claims was submitted - applicable adjusments - and account balances






14. 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






15. Patient who owes a balance on the account who has moved without a forwarding address






16. 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'






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






18. 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






19. Relationship between the amount of money owed and the amount of money collected






20. Insurance company that bids for a contract with CMS to handle the Medicare program in a specific area






21. Using ICD-9 codes to hughest degree






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






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






24. Insurance company that bids for a contract with CMS to handle the Medicare program in a specific area






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






26. Discount or fee exception given to a patient at the discretion of the physician






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






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






29. Physician has a seperate PPIN for each group/clinic in which they practices






30. List of CPT codes used by a physician with a corresponding fee that is usually calculated and maintained by a third-party payer






31. Amount of time allowed by an insurance company for a claim to be submitted for a payment from the date of service






32. Number is used instead of the individuals physician's number for the performing provider who is a member of a group practice that sybmits claims to insurance complanies under the group name






33. Working diagnosis which is not yet est.






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






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






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






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






38. Reimbursement directly sent from payer to provider






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






40. State based group of physicians working under government guideline to review cases and determine their appropriateness and quality of professional care






41. Electronic or paper-based report of payment sent by the payer to the provider






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






43. Request sent to an insurance comapany or other payer asking that a submitted claim be reconsidered for payment or processing






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






45. Codes used by insurance compaines to explain actions taken on a Remittance Notice






46. Codes used by insurance compaines to explain actions taken on a Remittance Notice






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






48. 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






49. Amount corrected on a patient ledger due to an error or a difference in the amount billed by a practice and the amount allowed by the insurance company






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







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