What is a Capitation rate?

PRE-paid per member per month charge

Who determines the content of both HIPAA 837P and CMS-1500 claims?

NUCC National Uniform Claim Committee

Deduct an amount from patient account. Never collected

What is a Contracted Fee Schedule

Fixed fee schedule with PAR providers

What does CMS stand for?

Center for Medicare and Medicaid Services

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MO143 Ch. 6 & 7 Part 2

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#MTI #MO143 chapter 6 and 7 Part 2

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Questions 15

Answers

1
If a provider's charge is HIGHER than the allowed amount, the reimbursement is based on
the amount allowed
the amount billed
2
What is a Capitation rate?
Fixed fee schedule with PAR providers
Deduct an amount from patient account. Never collected
Billing pt difference between usual fee and allowed amount
PRE-paid per member per month charge
3
What is the goal of the insurance specialist?
To make money
Submit Clean Claims
Write off as much as possible
Process claims as FAST as possible
4
How often does CMS update each part of the RBRVS?
Every year
Every 3 years
Every Quarter
Every Month
5
If the provider's charge is LOWER than the allowed amount, the reimbursement is based on
the amount billed
the amount allowed
6
The list of the Provider's usual charges?
Insurance Fee Schedule
Practice Fee Schedule
Provider Pricing List
Charge List
7
Who determines the content of both HIPAA 837P and CMS-1500 claims?
CMS Centers for Medicare and Medicaid Services
OIG Office of Inspector General
NUCC National Uniform Claim Committee
CCI Correct Coding Initiative
8
What is a write off?
Billing pt difference between usual fee and allowed amount
Deduct an amount from patient account. Never collected
PRE-paid per member per month charge
Fixed fee schedule with PAR providers
9
CCI stands for?
Correct Coding Initiative
Correct Computer Index
Controlled Coding Index
Computerized Coding Initiative
10
What is a Contracted Fee Schedule
Allowed amount insurance will pay
PRE-paid per member per month charge
Fixed fee schedule with PAR providers
Deduct an amount from patient account. Never collected
11
What does CMS stand for?
Content Management System
Center for Medicare and Medicaid Services
Content of Medicare and Medicaid Systems
Center for Medical Services
12
A company that scrubs claims and transmits electronic data to health plans
EMR
BCBS
billing clearing house
DDE
13
Who uses the Resource-based Relative Value Scale (RBRVS)?
Aetna
Tricare
Medicare
Blue Cross Blue Shield
14
Fee's based on typically charged amounts w/providers of similar training and skill are based in
Relative value scale
Conversion factor
Resource-based fee structure
Charge-based fee structure
15
The normal fee charged by the provider
Regular fee
Cash Price
Normal Schedule
Usual fee

MO143 Ch. 6 & 7 Part 2 Flashcards | StudBud