Electronic data interchange is

computer-to-computer exchange of data in a standard format

The open enrollment period is defined as

time when a policyholder selects from offered benefits

Admission of Liability is

determination that employer is responsible for pt's injury

managed care health plans under the MC Advantage program

Claim turnaround time is

time period in which a health plan must pay a claim

Blue Cross Blue-Shield Association is defined as

national association of independent companies

Medical data from which individual identifiers have been removed

de-identified health information

Program that covers employees and retirees & their families of the federal government is

Federal Employee Benefits Program

Patient charges in the hospitals vary according to:

their accommodations and services

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Reimbursement Methodologies

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Medical Insurance Exam Review

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Questions 100

Answers

1
Amount used to multiply a relative value unit to arrive at a charge is called
relative value unit
charge-based fee structure
conversion factor
2
To provide services to Medicaid recipients, physicians must sign a contract with
OIG
HHS
MIP
CMS
3
Normal fee charged by a provider is called
extra fee
late fee
usual fee
unusual fee
4
To reduce costs, many group health plans use limited networks of physicians & hospitals.
True
False
5
Electronic data interchange is
computer-to-computer exchange of data in a standard format
electronic exchange of healthcare information
accountable care organization
Health plan, clearinghouse or provider
6
Government health program serving dependents of active-duty service members
MTF
CHAMPVA
TRICARE
DEERS
7
All administrative & clinical functions that help capture & collect patient payments is called
revenue cycle
accounts payable
practice management
cash flow
8
The open enrollment period is defined as
When a person is first eligible for Medicare
period of 30 days before termination of benefits
90 day waiting period at the beginning of new employement
time when a policyholder selects from offered benefits
9
Admission of Liability is
program that provide reimbursement for lost income
determination that employer is responsible for pt's injury
insurance coverage for medical expenses
determination that employer is not liable for pt's injury
10
A government contractor that processes claims is called
MC administrative contractor
fiscal intermediary
carrier
PPO
11
Software that checks claims to permit error correction is called
No such software
claims scrubber
claims inquiry
claims auditor
12
Report summarizing the business day's charges and payments
noncollectable account
day sheet
cycle billing
payment plan
13
Computer assisting coding is a feature that allows a software program to assist assigning codes
False
True
14
A person who is financially responsible for the patient bill is called
payer
guarantor
insured
subscriber
15
Fixed amount that must be met by an individual before benefits begin
combined deductible
family deductible
individual deductible
cafeteria plan
16
The code 02103D4 is an example of which type of code?
ICD-9-CM
HCPCS
CPT
ICD-10-PCS
17
Which of the following are not consumer driven funding options to pay out-of-pocket costs?
Health savings account
Flexible savings account
Health reimbursement account
high deductible health plan
18
Description of a covered entity's principles and procedures related to protection of PHI is
protected health information
Designated record set
Notice of Privacy Practices
minimum necessary standard
19
Medicare Part C is
Supplementary Medical Insurance
MC prescription drug reimbursement plan
managed care health plans under the MC Advantage program
20
CMS-1500 is the current paper claim form approved by the NUCC.
True
False
21
Taxonomy codes are 10 digit administrative codes used to report a physician's specialty
False
True
22
Claim turnaround time is
all of the above
classifying A/R by length of time
state law obligating carriers to pay clean claims
time period in which a health plan must pay a claim
23
Embezzlement is the theft of funds by an employee or contractor.
False
True
24
Blue Cross Blue-Shield Association is defined as
national association of independent companies
national preferred provider organization
25
Account software used to schedule appointments, billing, & keep financial record is called
Human resource software
Data collection software
Practice management programs
Microsoft applications
26
Administrative code indicating where medical services were provided is called
Correct use code
code not required
Place of Service code
Date of service code
27
A fixed prepayment covering provider's services for a plan member for a specified period
participation
fee-for-serv ice
capitation
Health maintenance organization
28
Options a policyholder may purchase to add voluntary benefits such as vision & dental is called
Riders
Extras
Carve outs
none of the above
29
A process by which a patient authorizes medical treatment after discussion with a physician is
informed consent
law suit
compliance
malpractice
30
Payer of last resort is a regulation that Medicaid pays last on a claim.
False
True
31
The movement of monies into or out of a business is called
capitation
accounts payable
cash flow
accounts receivable
32
A TRICARE for life beneficiary must be at least
65
50
21
70
33
Portion of charges an insured must pay for covered services after the deductible is called
premium
deductible
out-of-pocket expense
coinsurance
34
Each state administers its own Workers' Compensation Plans
False
True
35
Under HIPAA, failure to transmit required data can cause a claim to be rejected by the payer.
True
False
36
Some individuals can be eligible for both Medicare and Medicaid.
False
True
37
Centers for Medicare and Medicaid Services is also know as
ACA
CMS
PPO
HMO
38
Providers must have patients' authorization to disclose PHI when it's not for TPO purposes.
False
True
39
Improper or excessive payments resulting from billing errors
insurance aging report
claims adjustment
MC Re-determination Notice
overpayment
40
Medical data from which individual identifiers have been removed
accounting of disclosures
protected health information
designated record set
de-identified health information
41
Program that covers employees and retirees & their families of the federal government is
Federal Group Health Plan
Federal Employee Benefits Program
Employee Retirement Income Security Act of 1974
Summary description plan
42
Pay for performance are health plans financial incentive programs based on provider performance
False
True
43
Manuals that describe how to perform major duties in most offices contain
accounting software manual
health information technology manual
productivity manual
policy & procedure manual
44
Patient charges in the hospitals vary according to:
their accommodations only
their accommodations and services
their age and gender
their services only
45
Document describing a payment resulting from a claim adjudication is called
development
remittance advice (RA)
concurrent care
medical necessity denial
46
Which laws govern the portability of health insurance?
FEHB and ERISA
COBRA and HIPAA
ERISA and HIPAA
PPO and HMO
47
On claims, MC will not accept signatures that
are electronic
are handwritten
is a fax of the original written/electronic signature
use a rubber stamp
48
Law with a number of changes including a prescription drug benefit
Medicare Advantage
MCS
HIPAA
Medicare Modernization Act
49
A document filed by the physician in a state workers' comp case when the pt is discharged is
discharge summary
progress report
first report of injury
final report
50
A specified amount a beneficiary must pay at the time of a healthcare encounter is called
copayment
preauthorization
referral
premium
51
Medigap is private insurance that can be purchased to pay the unpaid amounts in MC coverage
True
False
52
Document a patient signs to guarantee payment when a referral is pending
referral waiver
coordination of benefits
supplemental insurance form
pre-authorization
53
Which of the following is not a private health plan?
PPO - preferred provider ogranization
POS - point of service plan
Medicare/Medicaid
HMO - health maintenance organization
54
Relative Value Scale is a system of assigning unit values to services based on skill and time.
False
True
55
A program that shares healthcare costs for families of vets with 100% service disability is
DEERS
CHAMPVA
MTF
TRICARE
56
Administers programs for work-related illness or injury to by civilian employees of fed. gov't
Office of Workers' Compensation Program (OWCP)
Occupational Safety and Health Administration (OSHA)
57
Failure to use professional skill when giving medical care that result in injury is called
law suit
malpractice
standard of care
compliance
58
A list of medical expenses covered by a health plan is called
non-covered services
covered services
schedule of benefits
3rd party payer
59
Appeals must be filed
with the state insurance commissioner
by patients on behalf of relatives
by the provider for the patient
within a specified time
60
Coordination of benefits explains how an insurance policy pays if more than 1 policy applies
True
False
61
National Uniform Claim Committee is the organization responsible for claim content
True
False
62
Payer's process for determining medical necessity is called
Quality assurance
Utilization review
63
Person or organization that performs a function or activity for a covered entity is called
minimum necessary standard
health plan
Business Associate
protected health infomation
64
The smallest unit of information in a HIPAA transaction is called
item
none of the above
information
data element
65
A write off is a payer's lower allowed charge?
False
True
66
Medicare is financed jointly by the federal and state governments
True
False
67
The first step to establish insured patient's financial responsibility is
bill the patient credit card on file
identify next of kin in case patient can't pay
collect payment up-front from the patient
Verify patient's eligibility for insurace benefits
68
A place where medical care is provided to members of the military service & their families.
local acute care hospital
Military Treatment Facility
catchment area
Primary care office
69
Vocational rehabilitation programs are designed to prepare the patient to reenter the workplace
True
False
70
When hospital staff collects daya on a patient who is being admitted, the process is called
MSP
precertification
registration
health information management
71
Report grouping unpaid patients' bills by length of time they remain due is called
Fair Debt Collection Practice Act
collections
patient aging report
collection ratio
72
Method of converting a message into encoded text is called
all of the above
required by HIPAA security rule
is applied to data traveling between office and computer
encryption
73
TRICARE for Life is a program for beneficiaries who are both MC and TRICARE eligible.
True
False
74
Documentation template is a form used to prompt a physician to document medical necessity.
False
True
75
A denial of employer liability issued by workers' comp insurance carrier is called
Denial of Finding
No-Fault Notice
First Report of Liability
Notice of Contest
76
Guideline that states when a child is covered by 2 health plans , the father's plan is primary
gender rule
birthday rule
77
Insurance plan that pays benefits first
auto insurance
secondary insurance
primary insurance
supplemental insurance
78
Payment criterion that requires medical treatments to be appropriate & approved is called
preventive medical care
medical necessity
covered services
schedule of benefits
79
Document showing a beneficiary how the amount of benefit was determined is called
determination
explanation of benefits
medical necessity denial
remittance advice
80
The OIG Work Plan is the OIG's annual list of planned projects.
False
True
81
Gov't program that provides financial assistance for people with low income & few resources is
CHIP
Medi-Cal
Medi-Medi
Temporary Assistance for Needy Families (TANF)
82
The CHIP program offers health insurance coverage for uninsured
children
end stage renal disease patients
categorically needy
elderly
83
Upcoding is the payer's review and reduction of a doagnosis or procedure code
True
False
84
Under Medicare rules for patients in car accidents, the automobile insurance is
primary
secondary
supplemental
tertiary
85
Formal examination of a physician's or a payer's records is called
encryption
fraud
Omnibus rule
audit
86
a company that converts nonstandard transactions into standard transactions is called
clearinghouse
health plan
transaction
accountable care organization
87
Which of the following may be the same person as the patient?
pay-to-provider
destination payer
subscriber
referring provider
88
Money the insured pays to a health plan for a policy is called
coinsurance
premium
deductible
out-of-pocket expense
89
Medicare Part D covers
mammography
well visits
screening for cancer
prescription durgs
90
The amounts that providers bill for services performed are called
adjustments
charges
payments
All of the above
91
Under the Federal Medicaid Assistance program payments are made directly to
head of household only
CMS
individual states
individual precipitants
92
Charge capture are procedures that ensure billable services are recorded & reported for payment
False
True
93
Under the prospective payment system, payments for services are
set in advance
based on the provider's fees
not required from most patients
discounts to the provider's usual fees
94
Practices usually submit claims on behalf of their patients.
False
True
95
HIPAA stands for:
Includes HITECH
Health Insurance Portability and Accountability Act
Is part of Obama Care
Health Information Provisions and Accountability Act
96
The clinician primarily responsible for care of the patient from beginning of the episode
admitting physician
attending physician
ER physician
chief surgeon
97
Conditions in addition to the diagnosis on admission that affects the length of stay
complications
comorbidities
98
A MC program that pays for hospitalization, skilled nursing & home health care is called
Medicare Part C
Medicare Part D
Medicare Part B
Medicare Part A
99
Claim accepted by the health plan for adjudication is called
paper claim
claim scrubber
claim check
clean claim
100
Computerized MC system that controls improper coding leading to inappropriate payment is
CPT
ICD-10
Correct Coding Initiative (CCI)
Compliant billing

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