Which of the following processes makes a final determination for payment in an appeal board

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Bossier Parish Community College *

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200

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Health Science

Date

Oct 30, 2023

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docx

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1 Which of the following processes makes a final determination for payment in an appeal board? Arbitration HIPPA allows a health care provider to communicate with a patient's family, friends, or other persons who are involved in the patient's care regarding their mental health status providing the patient does not object In order to have claims paid as quickly as possible, the insurance specialist must be familiar with which of the following? Payers claim processing procedures Which of the following is necessary to complete a CMS- 1500 form? Diagnoses and CPT codes, physician information, demographic information When should a provider have a patient sign an ABN? When the items may be denied and prior to performing the service Which of the following forms should be transmitted to obtain reimbursement following a physician's office visit for a patient with active Medicaid coverage? CMS-1500 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 $20

2 coinsurance? Which of the following should an insurance and coding specialist do when check for completion of a new patient's registration form? Check that demographics are completed, Make sure that the patient's name matches the insurance card, Make sure that the registration form is signed and dated. When is a referral from a provider required? When contained in the individual policy 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? The husband's insurance The patient opted to have a tubal ligation performed. Which of the following is needed in order for the third party payer to cover the procedure? Pre-certification 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 an attachment explaining the error Which of the following protects federal healthcare programs from fraud and abuse by healthcare providers who solicit referrals? Anti-Kickback Statute

3 Which of the following patient information is needed to determine a Medicaid sliding fee scale? Poverty level, number of dependents, salary A patient has called to schedule an appointment for an office visit to see the doctor tomorrow for an earache. It was discovered during the scheduling process that the insurance policy on file has been cancelled. What do you do? Advise the patient to bring current insurance information to the appointment When there is a professional courtesy awarded to a patient's account the insurance and coding specialist should post the amount under the? adjustment column When the patient has signed the assignment of benefits form, the payment for services should be sent to the provider unless the provider is Out of network When posting transactions for electronic claims submission, it is necessary to enter which of the following items into the claim? Physician's office fee When using an EHR system to enter CPT codes on a CMS-1500 claim form for electronic submission, which of the following should be entered on the claim form first? The most resource-intensive procedure or service

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4 A patient was seen in the office. Charges were recorded and submitted to the patient's insurance, and an EOB was received by the office with a payment of $70.89. These transactions should be recorded in the ? Patient ledger When a capitation account is applied to the ledger it is also known as a Monthly prepayment amount When using the EHR to schedule a patient visit, which of the following screens should be used to complete the scheduling process? Patient Search Which of the following fees posted to the patient's account is an example of "usual, customary, and reasonable?" Allowed amount When filing an electronic claim, the insurance and coding specialist processes which of the following forms? CMS-1500 The patient is sent a statement for an office visit. The total amount of the bill is $100.00, and this amount must be paid before the insurance company will pay on the claim? It’s called? Deductible Collecting statistics on the frequency of copay collection at managing A/R

5 time of service is a step in the process of The provider is paid the same rate per patient whether or not they provide services, and no matter which services were provided. This payment is known as Capitation A new HIM director was recently hired at a hospital. She was advised her health insurance benefits to become available in 90 days. Which of the following is correct regarding her health insurance? She will be able to keep her current medical insurance from her previous job through COBRA Which of the following are violations of the Stark Law? Accepting gifts in place of payments from patients, referring patients to facilities where the provider has a financial interest 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 both his insurance benefits and his wife's insurance benefits Which of the following is an appropriate way to open the discussion when explaining practice fees to a patient? "Do you have any questions about the cost of today's visit?" When a document is changed in hidden

6 an EHR, the original documentation is? Which of the following information is necessary to post payments from the RA/EOB? billed CPT codes, patient's name, date of service Developing an insurance claim begins when the patient calls to schedule an appointment The most effective method to manage patient statements and other financial invoices as well as avoid payment delays is to Collect fees at the time of service Which of the following financial reports produces a quarterly review of any dollar amount a patient still owes after all insurance carriers claim payments have been received? Aging The Fair Debt Collection Practices Act restricts debt collectors from engaging in conduct that includes Calling before 8:00am or after 9:00pm unless permission is given 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 Co-insurance is typically due after the claim has been adjudicated

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7 When following up on a denied claim, an insurance and coding specialist should have which of the following info available when speaking with the insurance company? Date of service, Physician's NPI, patient's insurance ID number 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 False Claims Act