campbell 17 final

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  1. Providing additional clinical information to an insurance company as part of an attempt to overturn a claim denial is known as submitting a what?
    Appeal
  2. Some insurance carriers perceive automatic rebilling after 30 days to be aggressive and what kind of practice?
    Fraudulent
  3. Reasons to rebill an insurance claim include all of the following except: the Medical Office Specialist made a mistake on the claim, Charges on the original claim ere not detailed, the patient was not eligible when the initial claim was filed, Some of the services provided to a patient were not billed on prior claims.
    The patient was not eligible when the initial claim was filed.
  4. An examination and verification of claims and supporting documentation submitted by a physician is a what?
    Audit
  5. If a claim is denied as a non-covered service, the medical office specialist should do what?
    Bill the patient
  6. If a claim is denied because services were provided before insurance coverage was in effect, the medical office specialist should do what?
    Bill the patient.
  7. If a claim is denied because additional information is needed to prove medical necessity, the medical office specialist should do what?
    Submit the requiremed information and follow up with the carrier
  8. The patient is responsible for payment when a claim is denied because services were for treatment of a preexisting condition.
    True
  9. The patient is responsible for payment when a claim is denied because services were provided after coverage was cancelled.
    True
  10. The patient is responsible for payment when a claim is denied because services were provided that were not preauthorized.
    False
  11. The patient is responsible for payment when a claim is denied because services were provided before coverage was in effect.
    True
  12. If a patient is upset about a claim denial, the medical office specialist should do all of the following except: Explain in simple language why the company denied payment, Ask the patient to call the insurance company and try to get them to reconsider, Use respect and care when explaining policy benefits, If the denial was due to a need for additional information, submit the additional information immediately and let the patient know it has been done.
    Ask the patient to call the insurance company.
  13. After an appeal fails, when an objective, unbiased group of physicians determines what payment is adequate for services provided, the process is called what?
    Peer review
  14. If a physician requests a peer review that results in confirmation that services were not medically necessary, who pays for the review?
    The physician pays for the review
  15. Who can ask the state insurance commissioner for help in resolving a payment dispute?
    Patients, physicians, and insurance carriers
  16. The chronological recording of pertinent facts and observations regarding a patient’s health status is known as what?
    Documentation
  17. From the insurance carrier’s perspective, if a service is not documented in the medical record, what does this mean?
    The services was not performed
  18. What is SOAP an anagram for?
    Subjective, Objective, Assessment, and Plan
  19. Which part of SOAP is the patient’s chief complaint and reason for encounter?
    Subjective
  20. Which part of SOAP is the evaluation and management (E/M) history that the physician takes?
    Subjective
  21. What part of SOAP is the documentation of the physical exam that the doctor performs?
    Objective
  22. What part of SOAP is the diagnosis?
    Assessment
  23. What part of SOAP is the physician’s recommended treatment, testing, or therapy?
    Plan
  24. What part of SOAP is the documentation of vital signs, height, weight, and blood pressure?
    Objective
  25. What part of SOAP is the documentation of the physician’s medical decision making?
    Assessment
  26. What part of SOAP are the medication recommendations?
    Plan
  27. Which of the following are ways that the medical office specialist can learn about an insurance carrier’s appeals process? An administrative manual, Newsletters from the carrier, Phone call to the carrier
    All of the above.
  28. What information should be included when appealing disallowances resulting from low maximum allowable fees?
    Payment amounts from other carriers for the same reported service
  29. What information should be included when appealing a denial made because the carrier doesn’t believe the services to be medically necessary?
    Documentation from the patient’s record.
  30. All of the following claims can be appealed by telephone except those in which: A modifier was used to indicate multiple procedures that the carrier bundled, The claim was considered not medically necessary, The carrier requested information from the patient that was not received, The patient had a routine service covered by the policy.
    The carrier requested information from the patient that was not received.
  31. What are two ways simple appeals are typically accepted?
    Telephone or fax
  32. An appeal must be made in writing if a billing error was made by the medical assistant.
    True
  33. An appeal must be made in writing if the carrier requested information from the patient that was not received.
    False
  34. An appeal must be made in writing if the patient had a routine service covered by the policy.
    False
  35. An appeal must be made in writing if the claim was for services related to an accident.
    False
  36. Which benefit plan is not coverd by the Employee Retirement Income Security Act (ERISA)?
    Church plans
  37. What is the law that protects the interests of beneficiaries enrolled in private employee benefit plans called?
    ERISA
  38. What does ERISA stand for?
    Employee Retirement Income Security Act
  39. According to ERISA, a plan must pay a claim or respond regarding its status within how many days?
    90 days
  40. According to ERISA, a carrier must provide a decision on an appeal within how many days?
    120 days
  41. According to ERISA, a provider must file an appeal within how many days?
    60 Days after the denial
  42. What is a Level I Medicare appeal?
    Request for redetermination by the carrier
  43. What is a Level II Medicare appeal?
    Request for review by a qualified independent contractor.
  44. What is a Level III Medicare appeal?
    Request for review by an administrative judge.
  45. How long do qualified independent contractors have to process a reconsideration?
    30 days
  46. How long do Medicare carriers have to process a redetermination?
    30 days
  47. How long do physicians have to file a Medicare appeal with an administrative judge?
    60 days
  48. What is the minimum dollar amount that a claim must be for a Level III appeal with an administrative judge?
    $130
  49. What is the number one reason that Medicare Part B claims are returned?
    No valid signature
  50. What is a disallowance?
    When a provider receives a partial payment on a claim because the amount billed was in excess of the maximum allowed charge.
  51. What percent of denied claims are typically overturned on the first appeal?
    25%
  52. When a denial by a self-funded plan is upheld, who should the medical office assistance appeal to?
    The Department of Labor
  53. When a denial is upheld that contained regulatory information in the original appeal, who should the medical office assistant appeal to?
    The carrier’s legal counsel
  54. In general, Medicare can request refunds for overpayment to providers for up to how long?
    5 years
  55. What is the statute of limitations for refunds in cases that have no contract language to cover refunds?
    4 years
  56. Wrongfully keeping an overpayment is illegal and is called what?
    Conversion
Author:
bbhagan
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Card Set:
campbell 17 final
Updated:
2015-12-15 21:27:19
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