Which of the following reports is used to follow up on outstanding claims to third party payers?
financial
aging
accounts payable
audit
Which of the following is the most likely cause of the deposits not agreeing with the credits on the day sheet or the patient ledgers?
there are duplicate cards
the bank made an error
cash is missing
payment is misplaced
When following up on a denied claim, an insurance and coding specialist should have which of the following information available when speaking with the insurance company? (Select the three (3) correct answers).
physician’s NPI
date of service
date the claim was denied
patient’s mailing address
patient’s insurance ID number
A third party payer made an error while adjudicating a claim. Which of the following should the insurance and coding specialist do?
Resubmit the claim with a correction.
Resubmit the claim with an attachment explaining the error.
Contact the patient to make payment arrangements.
Contact the insurance commissioner.
Which of the following information is necessary to post payments from the RA/EOB? (Select the three (3) correct answers.)
diagnosis codes
patient’s name
patient’s date of birth
billed CPT® codes
Which of the following processes makes a final determination for payment in an appeal board?
arbitration
deposition
peer to peer
special handling
A Medicare patient has an 80/20 plan. The charged amount was $300.00. The amount allowed was $100.00. Which of the following is the patient's coinsurance?
$100
$80
$20
$60
How often should the encounter form CPT® codes be updated?
monthly
semi-annually
quarterly
annually
If a married couple is covered under both spouses’ health insurance and the husband wishes to schedule an appointment for an annual exam, he should call his primary care provider and
schedule an appointment using just his insurance benefits.
schedule an appointment using both his insurance benefits and his wife’s insurance benefits.
his wife’s primary care provider and schedule an appointment to visit with both.
his wife’s primary care provider to see which has the earliest appointment available.
The insurance and coding specialist is billing the insurance company of a 66-year-old woman who has Medicare and is covered under her husband’s private insurance. Which of the following should be billed first?
Medigap
the husband’s insurance
Medicare
Medicaid
Encounter forms should be audited to ensure the
practice information is included on each encounter.
diagnosis is in proper ICD-10-CM format.
patient’s vitals are present.
payer’s address and phone are current.
Which of the following regulations prohibits the submission of a fraudulent claim or making a false statement or representation in connection with a claim?
Federal Claims Collection Act
Federal False Claims Act
Anti-Kickback Law
Stark Law
Which of the following is an appropriate way to open the discussion when explaining practice fees to a patient?
“We will bill you for the visit in full.”
“We can accept your insurance as payment in full.”
“Do you know what your out of pocket cost is today?”
“Do you have any questions about the cost of today’s visit?”
When using the EHR to schedule a patient visit, which of the following screens should be used to complete the scheduling process?
accounts receivable
correspondence
clinical care
patient search
When posting an insurance payment via an EOB, the amount that is considered contractual is the
patient responsibility.
co-insurance.
NON-PAR payment allowable.
insurance allowed amount.
Which of the following items are mandatory in patient financial policies? (Select the three (3) correct answers.)
participating insurance companies
statement that responsibility for payment lies with patient
provider fee schedule
collection process
expectation of payment due at time of service
When posting transactions for electronic claims submission, it is necessary to enter which of the following items onto the claim?
insurance plan’s UCR fee
insurance plan’s allowable fee
physician’s contractual fee
physician’s office fee
A claim submitted with all the necessary and accurate information so that it can be processed and paid is called a
allowable claim.
clean claim.
closed claim.
timely filing.
Which of the following defines the maximum time that a debt can be collected from the time it was incurred or became due?
practice management payment policy
statute of limitations
benchmark
When is a referral from a provider required?
when contained in the individual policy
if a patient goes to a network hospital for services
for Workers’ Compensation patients
within 24 hours of a medical procedure
Which of the following must a patient sign prior to an insurance claim being processed?
a referral form
the HIPAA waiver form
an Authorization to Release Information
the actual insurance claim form
Which of the following is the correct procedure for keeping a Workers' Compensation patient’s financial and health records when the same physician is also seeing the patient as a private patient?
Separate financial and health records must be used.
The same financial and health records may be used.
The same health record may be used, but a separate financial record must be maintained.
The same financial record may be used, but a separate health record must be maintained.
If the insurance and coding specialist suspects Medicare fraud she should contact the
DOJ
OIG
FDA
AMA
Which of the following are violations of the Stark Law? (Select the two (2) correct answers.) upcoding
billing for services not rendered
referring patients to facilities where the provider has a financial interest
negligent handling of protected health information (PHI)
accepting gifts in place of payment from patients
The insurance and coding specialist calls a carrier to verify a patient’s insurance and the representative states that the patient’s insurance was canceled three months ago. Which of the following should the insurance and coding specialist do first?
Record the information and refer the patient to another provider.
Discuss self-pay options with the insurance policy holder.
Ask the patient for another form of insurance coverage.
Ask the patient to reschedule the appointment.
In order to have claims paid as quickly as possible, the insurance specialist must be familiar with which of the following?
payer's claim processing procedures
prompt pay laws
clearinghouse processing procedures
automated claims status requests
Developing an insurance claim begins
once the charges have been entered into the computer.
when the patient calls to schedule an appointment.
after the medical encounter is completed.
when the patient arrives for the appointment.
Which of the following protects federal healthcare programs from fraud and abuse by healthcare providers who solicit referrals?
Fraud and Abuse Act
Anti-Kickback Statute
Utilization Review Act
A Medicare patient presents to an outpatient hospital facility for a scheduled hysterectomy. To which Medicare plan should the facility submit the claim?
PART A
PART B
PART C
PART D
If the insurance carrier’s rate of benefits is 80%, the remaining 20% is known as
CAPITATION
COPAYMENT
DEDUCTIBLE
COINSURANCE
A patient has two health insurance policies – a group insurance plan through her full-time employer and another group insurance plan through her husband’s employer. Which of the following policies should be billed as primary?
the policy with the highest coverage
husband’s policy
both policies
her policy
When filing an electronic insurance claim, the insurance and coding specialist processes which of the following forms?
CMS-1500
assignment of benefits
encounter form
HIPAA waiver
When a capitation account is applied to the ledger it is also known as a
fee for service.
copayment amount.
monthly prepayment amount.
monthly premium.
