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. 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






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






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






4. 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






5. Term for processing payment






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






7. Take what insurance pays






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






9. Amount charged by a practice when providing services






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






11. Term for processing payment






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






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






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






15. 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






16. 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






17. 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






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






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






20. 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`






21. 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






22. 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






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






24. 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






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






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






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






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






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






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






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






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






33. Federal Employees' Compensation Act






34. 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






35. 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






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






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






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






39. Bundling edits by CMS to combine various component items with a major service or procedure






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






41. Record to track patients charges - payments - adjustments - and balance due






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






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






44. 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






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






46. Assigned to the physician by Medicare program






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






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






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






50. 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