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






2. 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






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






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






5. Federal Employees' Compensation Act






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






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






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






9. Listing of claims that have incorrect information such as posting error or missing information to process a claim






10. Early and Periodic Screenings - Diagnosis - and Treatment






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






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






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






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






15. 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






16. 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






17. 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






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






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






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






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






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






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






24. Amount representing the charge most frequently used by a physician in a given periord of time






25. Process of converting diagnoses - procedures - and services into numeric and alpha-numeric characters






26. 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'






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






28. 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






29. Process of converting diagnoses - procedures - and services into numeric and alpha-numeric characters






30. 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






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






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






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






34. 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






35. 1.Claims submission-transmission of claims data either electronically or manually to third party payers or clearinghouse for processing 2.Claims processing- thrid party payers and clearinghouse verify the information found and submitted claims about






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






37. Amount charged by a practice when providing services






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






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






40. 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






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






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






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






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






45. Reimbursement directly sent from payer to provider






46. Number assigned by insurance companies to a physician who renders service to patients






47. Working diagnosis which is not yet est.






48. Take what insurance pays






49. Physician must obtain this number in order to practice within a state






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