🌟Medical Insurance Management- CH 17

If a service is not covered by Medicare, which action is required?

The patient must sign an ABN prior to receiving the service

In the Medicare claims appeal process, what is final or highest level of appeal?

Federal Court Review

To properly follow up on unpaid claims, how should the claims be logged or sorted?

By the date of service

The National Provider Identifier (NPI) number serves as a unique identifier for physicians who do which of the following?

Submit health insurance claims

Which central location are claims received, edited, and distributed electronically to insurance companies?

Clearinghouse

Which application is used when submitting electronic claims?

ECT

What is an Advance Beneficiary Notice?

A document informing the patient that Medicare may not pay for services and the patient will be responsible for payment

What may be filed with the insurance company if a valid claim has not been paid after multiple inquiries and/or a denial has been received?

Appeal

When would the medical assistant attach a copy of the assignment of benefits to every insurance claim?

Every claim should have a copy of the assignment of benefits attached

When a third-party payer identifies an error on the clam form, the claim is:

Rejected with a request to resubmit the form with corrections

If the date of service for a Medicare claim is February 14, 2023, what is the maximum date to file the claim?

February 14, 2024

When completing a paper claim form for OCR processing, which symbols can be used on the form?

Alpha or numeric symbols only

Electronically processing claim forms to insurance carriers:

Reduces the amount of preparation time for the insurance clerk, saves money and increases cash flow

The CMS-1500 paper form when allowed is accepted by

Medicare, private insurance companies, and various government insurers

What is the first step in completing a claim form?

Check to see if the patient’s signature is on file for release of information

The False Claim Act covers fraud involving which entity?

Any federally funded program

What is the maximum time frame to appeal a determination from a Medicare audit?

120 days

Which action should the medical assistant take if a claim is denied?

Provide documentation for the time spent and skill of the physician to the insurance company

How long are copies of the ABN required to remain on file?

3 years

What is the time limit for filing a Medicare/Medicaid claim?

1 year

What is the statute of limitations for filing fraudulent claims?

10 years

What is a “taxonomy code” on a claim form used to designate?

The physician’s specialty

What is the time frame for filing Medicare claims?

12 months after date of service

If an assignment of benefits form is not signed by the patient, what happens to the insurance payment?

The insurance company sends the check to the patient’s home

The steps to file a third-party claim and accurately complete the CMS-1500 form include:

All of the responses are correct

If the insurance normally pays claim within 45 days and multiple claims have not been paid within 60 days, which would be the medical assistant’s next step?

Send a separate email for each claim

What is it called when a Medicare/Medicaid claim is filed?

A crossover claim

If Medicare sends an ADR, how many days does the medical assistant have to respond before the claim is denied?

45 days

Which action would be considered fraud and abuse under the False Claims Act?

Billing separately for bundles services

What is the guideline for a signed consent to release medical information for treatment, payment, and health care operations?

It is mandated by HIPAA