MAP179 Chap 15 Medical Billing and Reimbursement Exam Questions and Answers.
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Course
MAP179
Institution
MAP179
MAP179 Chap 15 Medical Billing and ReimbursementExam
Questions and Answers.
The process of obtaining the dollar amount approved for a medical procedure or service
before the procedure or service is scheduled. - Correct Answer Precertification
Obtained from health insurance companies and gives t...
MAP179 Chap 15 Medical Billing and Reimbursement Exam
Questions and Answers.
The process of obtaining the dollar amount approved for a medical procedure or service
before the procedure or service is scheduled. - Correct Answer Precertification
Obtained from health insurance companies and gives the provider approval to render the
medical service. - Correct Answer Preauthorization
The electronic transfer of data (e.g. electronic claims) between two or more entities. -
Correct Answer Electronic data interchange
A process done prior to claims submission to examine claims for accuracy and
completeness. - Correct Answer Audit
A contract between a provider and an insurance company in which the health plan pays a
monthly fee per patient while the provider accepts the patient's copay as payment in full
for office visits. - Correct Answer Capitation agreements
The process of obtaining the dollar amount approved for a medical procedure or service
before it is scheduled. - Correct Answer Precertification
Form used by most health insurance payers for claims submitted by providers and
suppliers. - Correct Answer CMS-1500
Process by which an insurance carrier allows a provider to submit insurance claims
directly to the carrier electronically. - Correct Answer Direct billing
A healthcare provider who has signed a contract with a health insurance plan to accept
lower reimbursements for services in return for patient referrals. - Correct Answer
Participating provider
An intermediary that accepts the electronic claim from the provider, reformats the claim to
the specifications outlined by the insurance plan, and submits claim. - Correct Answer
Claims clearinghouse
, An identifier assigned by the Centers for Medicare and Medicaid Services (CMS) that
classifies the healthcare provider by license and medical specialties. - Correct Answer
National Provider Identifiers (NPI)
On the EOB where the payer indicates the conditions under which the claim was paid or
denied. - Correct Answer Remark codes
Found on the patient's health insurance ID card and is needed to identify the specific
health plan to which the claim should be submitted. - Correct Answer Transmitter
When provider may be inclined to code to a higher specificity level than the service
provided actually involved. - Correct Answer Upcoding
Claims with incorrect, missing, or insufficient data. - Correct Answer Dirty claims
A form that is sent by the insurance company to the provider who submitted the insurance
claim with an accompanying check or a document indicating that funds were electronically
transferred. - Correct Answer Explanation of Benefits (EOB)
Insurance carrier's decision if the tests and treatments indicated by the CPT and HCPCS
codes meet the accepted standard of practice to treat the patient's diagnosis indicated by
the ICD code. - Correct Answer Medical necessity
A patient financial responsibility that the subscriber for the policy is contracted per year to
pay toward his or her healthcare before the insurance policy reimburses the provider. -
Correct Answer Deductible
When a lower specificity level, or more generalized code, is assigned. - Correct Answer
Downcoding
A policy provision in which the policyholder and insurance company share the cost of
covered medical services in a specified ratio. - Correct Answer Coinsurance
A patient financial responsibility that is due at the time of the office visit. - Correct Answer
Copayment
Determining whether fraudulent medical billing practices were done with purpose or by
accident. - Correct Answer Intentional
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