Chapter 4 Study Guide

1. Chapter 4 Study Guide Developing an Insurance Claim

2. 1. The patient’s financial record, which can be found in automated or manual format is the a. Day sheet c. patient ledger • Encounter form d. remittance advice 2. The specified percentage of charges that patient must pay to the provider for each service received or for each visit is the a. Coinsurance c. deductible b. Copayment d. premium

3. 3. The financial record source document used to record services rendered in a physician’s office is the a. Chargemaster c. patient ledger • Encounter form d. remittance advice 4. When the provider is required to receive as payment in full whatever amount the insurance reimburses for services, the provider is agreeing to a. Accept assignment c. authorize services b. Assignment of benefits d. coordination of benefits

4. 5. Care rendered to a patient that was not properly approved, (e.g., preapproved) by the insurance company is known as A Medical necessity c. unapproved services • Noncovered benefits d. unauthorized services 6. The maximum amount the payer will allow for each procedure or service, according to the patient’s policy, is the a. Allowable charge c. denied charge b. Chargemaster d. maximum charge

5. 7. Approximately how many insurance claims are filed each year? a. 100 million c. 5 billion • 600 million d. more than 6 billion 8. The development of a claim begins at a. Clearinghouse c. payer’s office b. Patient’s place of employment d. provider’s office

6. 9. In the development of a claim, data transmitted electronically or manually to payers or clearinghouses for processing is called claims a. Adjudication c. processing • Payment d. Submission 10. According to the national standards mandated by HIPAA for the electronic exchange of administrative and financial care transactions, which would be a covered entity? a. Managed care organization b. Multispecialty group practice that conducts only paper- based transactions c. Provider who conducts only paper-based transactions d. Small, self-identified health plan

7. 11. The private, nonprofit organization that administers and coordinates the US private-sector voluntary standardization system is a. ANSI c. ERISA • CMS d. HIPAA 12. If a claim is found to contain all the data elements required for processing, it is known as a ___________________ claim. a. Clean c. suspended b. Processed d. valid

8. 13. A procedure reported on a claim that is not included on the master benefit list will result in ________________ of a claim. a. Aging c. resubmission • Denial d. Suspension 14. The remittance advice has what name in the Medicare program? a. Encounter form c. Medicare Summary Notice • Explanation of Benefits d. Provider Remittance Notice 15. The person responsible for paying the charges for services rendered by the provider is the a. Beneficiary c. guardian b. Guarantor d. subscriber

9. 16. Which document is used to generate the patient’s financial and medical record? a. Encounter form c. patient ledger • Patient insurance card d. patient registration form 17. The rule stating that the policy holder whose birth month and day occur earlier in the calendar year holds the primary policy for dependent children is the ________________ rule. a. Birthday c. policy b. Gender d. primary

10. 18. To save the expense of mailing invoices to patients, the office may ask the patient to a. Come back on payday and pay the portion of the bill b. Leave a self-addressed, stamped envelope with the office c. Pay the patient’s portion of the bill before treatment of before the patient leaves the office • Set up an electronic funds transfer account 19. How long must providers retain copies of government insurance claims? a. 30 days c. seven years b. One year d. permanently

11. 20. What type of claim is generated for providers who do not accept assignment? a. Delinquent c. suspended • Rejected d. Unassigned 21. The process of submitting multiple CPT codes when one code should be submitted is a. Downcoding c. unbundling b. Segmenting d. upcoding

12. 22. The insurance industry is regulated by whom? • American Medical Association • Centers for Medicare/Medicaid Services c. Government • individual states 23. The development of a claim typically consists of how many stages? a. Four c. seven b. Five d. six

13. 24. Providers can communicate directly with payers by use of technology that emulates a system connection known as a(n) a. Dial-up connection c. facsimile • Extranet d. magnetic tape 25. When a provider performs a procedure for which is no CPT or HCPCS level II code is available, what must be provided to the payer? a. Additional ICD-9-CM codes c. patient’s financial record b. Patient’s medical record d. supporting documentation