Revenue Management Insurance Claims, Denied Claims and Appeals

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Highline College *

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141

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Law

Date

May 6, 2024

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pdf

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3

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4.1 - Multiple Choice Instructions: Select the most appropriate response. 1. The electronic or manual transmission of claims data to payers or clearinghouses is called claims a. adjudication. b. attachment. c. processing. @ submission. 2. A seri 0 Q,o,,jQT fixed-length records submitted to payers to bill for health care services is an electronic flat file format. . funds transfer. c. remittance advice. d. source document. 3. For the purpose of processing electronic claims, which is considered a covered entity? a. Organizations that accredit clearinghouses /[) Private-sector payers that process electronic claims Providers that submit paper-based CMS-1500 claims d. Small self-administered health plans that processes manual claims 4. A claim that is rejected because of an error or omission is considered a(n) a. clean claim. b. closed claim. c. delinquent claim. {d.")d. I • "\._/ open cairn. 5. Which supporting documentation is associated with submission of an ·,nsu t • ? . . ranee c aim . ~; Ac~ounts receivable aging report ~:) Claims attachment c. Common data file d. Electronic remittance advice
6. The sorting of claims upon submission to collect and verify information about the patient and provider is called claims a. adjudication. b. preauthorization. a\_. processing. Y. submission. 7. Which of the following steps would occur first during the insurance claim cycle? a. The clearinghouse converts electronic claims into electronic flat file format. b. The clearinghouse verifies claims data and transmits to payers. c. The health insurance specialist batches claims and submits to clearinghouse. /. d\ The medical practice rnanngen1ent software generates electronic claims. 8. Comp~g the claim to payer edits anci tl,E. r,atient.·s health plan bE?nefits is part of claims ~-- adjudication. b processing. c. submission. d. transmission. 9. Which describes any procedure or service reported on a claim that is not included on the payer's master benefit list? a. Medically unnecessary @ Noncovered benefit c. Pre-existing condition d. Unauthorized service 10. Which is a summary abstract report of all recent claims filed on each patient, which is used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provid~ a. Common data file . Encounter form c. Patient ledger d. Remittance advice 11. Which is the fixed amount patients pay each time they receive health care services? a. Coinsurance (§) Copayment c. Deductible d. Insurance 12. Which of the following steps would occur first? I" a. The clearinghouse transmits claims data to payers. '-1?.' The payer approves claim for payment. c. The payer generates remittance advice. d. The payer performs claims validation. 13. Refer to Figure 4-11 in this chapter. Which payer's claim(s) should be followed up first to obtain reimbursement? a. Aetna of California b. BlueCross BlueShield of Florida c. Home Health Agency Medicaid
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