Insurance Chapter 4: Prossessing An Insurance Claim (2024)

Table of Contents

Which means that the paitent and or insured has authorized the payer to reimburse the provider directly? Providers who o not accept assignment of Medicare benefits do not receive information included in the ______, which is sent to the patient. The transmissions of claims data to payers or clearinghouses is called claims... Which facilitates processing of nonstandard claims data elements into standarddata elements? A series of fixed length records submitted to payers to build for health care services is an electronic Which is considered a covered entity? A claim that is rejected because of an error or an omission is considered an An electronic claim is submitted by using _________ as its transmission media. Which supporting documentation is associated with submission of an insurance claim? Which is a group health insurance policy provision that prevents multiple payers from reimbursing benefits by other policies? The sorting of claims upon submission to collect and verify information about the patient and provider is called claims Which of the following steps would occur first? Comparing the claim to payer edits and the patients health plan benefits is part of claims... Which describes any procedure or service reported on a claim that is not included Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider? Which is the fixed amount patients receive each time they receive health care services? Which of the following steps would occur first? Which must accept whatever a payer reimburses for procedures or services performed? Which is an interpretation of the birthday rule regarding two group health insurance policies when the parents of a child covered on both policies are married to each other and live in the same household? Which is the financial record source document usually generated by a hospital? (Refer to figure 4-20 of chapter 4) Which payers claim should be followed up first to obtain reimbursem*nt? Which protects information collected by consumer reporting agencies? Which protects information collected by consumer reporting agencies? Which is the best way to prevent delinquent claims? Which is a characteristic of delinquent commercial claims awaiting payer reimbursem*nt? FAQs

1.
Which means that the paitent and or insured has authorized the payer to reimburse the provider directly?
- A.
  Accept assignment
- B.
  Assignment of benifits
- C.
  Coordination of benifits
- D.
  Medical necessity
Correct Answer
B. Assignment of benifits
Explanation
Assignment of benefits refers to the process in which a patient or insured individual authorizes the payer (such as an insurance company) to reimburse the healthcare provider directly. This means that the patient does not need to pay the provider out-of-pocket and then seek reimbursem*nt from the payer. Instead, the provider can directly receive payment from the payer, making it more convenient for the patient.
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01
2.
Providers who o not accept assignment of Medicare benefits do not receive information included in the ______, which is sent to the patient.
- A.
  Electronic flat file
- B.
  Encounter form
- C.
  Ledger
- D.
  Medicare summary notice
Correct Answer
D. Medicare summary notice
Explanation
Providers who do not accept assignment of Medicare benefits do not receive information included in the Medicare summary notice, which is sent to the patient. The Medicare summary notice is a document that provides a summary of the services or supplies billed to Medicare on the patient's behalf. It includes information such as the date of service, the provider's name, the service provided, the amount billed, and the amount Medicare paid. This notice is sent to the patient to inform them about the services they received and the financial responsibility they may have.
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3.
The transmissions of claims data to payers or clearinghouses is called claims...
- A.
  Adjucation
- B.
  Assignment
- C.
  Processing
- D.
  Submission
Correct Answer
D. Submission
Explanation
The term "claims submission" refers to the process of sending claims data to payers or clearinghouses for processing and reimbursem*nt. This involves submitting all the necessary information and documentation related to the claim for review and evaluation. The other options provided - adjudication, assignment, and processing - are not specifically related to the act of transmitting claims data, making them incorrect choices.
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4.
Which facilitates processing of nonstandard claims data elements into standarddata elements?
- A.
  Clearinghouse
- B.
  EHNAC
- C.
  Payer
- D.
  Provider
Correct Answer
A. Clearinghouse
Explanation
A clearinghouse is a system that helps in the processing of nonstandard claims data elements into standard data elements. It acts as an intermediary between healthcare providers and payers, receiving claims data in various formats and converting them into a standardized format that can be easily understood and processed by the payer. This ensures seamless communication and efficient processing of claims, reducing errors and improving overall workflow in the healthcare industry.
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5.
A series of fixed length records submitted to payers to build for health care services is an electronic
- A.
  Flat file format
- B.
  Funds transfer
- C.
  Remittance adice
- D.
  Source document
Correct Answer
A. Flat file format
Explanation
The correct answer is flat file format. A series of fixed length records submitted to payers to bill for healthcare services refers to a format in which the data is stored in a file with a fixed structure, where each record has a predetermined length. This format is commonly used for electronic data interchange in the healthcare industry, allowing for the efficient transfer of information between systems.
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6.
Which is considered a covered entity?
- A.
  EHNAC which accredits clearinghouses
- B.
  Private sector payers that process electronic claims
- C.
  Provider that submits paper based CMS-1500 claims
- D.
  Small self administered health plan that processes manual claims
Correct Answer
B. Private sector payers that process electronic claims
Explanation
Private sector payers that process electronic claims are considered a covered entity. This means that they are subject to HIPAA regulations and are required to comply with privacy and security standards to protect the health information of their patients.
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See Also
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7.
A claim that is rejected because of an error or an omission is considered an
- A.
  Clean claim
- B.
  Closed claim
- C.
  Delinquent claim
- D.
  Open claim
Correct Answer
D. Open claim
Explanation
An open claim refers to a claim that has been submitted but not yet processed or finalized by the insurance company. In this context, a claim that is rejected due to an error or omission would still be considered an open claim because it is still pending resolution. Once the error or omission is corrected and the claim is resubmitted, it can then be processed and either approved or denied. Therefore, an open claim is the most appropriate term to describe a rejected claim that is still awaiting resolution.
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8.
An electronic claim is submitted by using _________ as its transmission media.
- A.
  Facsimile machine
- B.
  Magnetic tape
- C.
  Scanning device
- D.
  Software that prints claims
Correct Answer
B. Magnetic tape
Explanation
An electronic claim is submitted using magnetic tape as its transmission media. Magnetic tape is a medium that stores data in a magnetic form and is commonly used for transferring large amounts of data between systems. It allows for efficient and reliable transmission of electronic claims from one system to another.
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9.
Which supporting documentation is associated with submission of an insurance claim?
- A.
  Accounts recievable
- B.
  Claims attachment
- C.
  Common data file
- D.
  Electronic remittance advice
Correct Answer
B. Claims attachment
Explanation
When submitting an insurance claim, a claims attachment is the supporting documentation that is associated with it. This attachment provides additional information and evidence to support the claim being made. It could include items such as medical records, invoices, receipts, or any other relevant documents that help validate the claim being submitted. The claims attachment serves as proof or documentation of the expenses or damages being claimed, and it helps the insurance company assess the validity and accuracy of the claim.
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10.
Which is a group health insurance policy provision that prevents multiple payers from reimbursing benefits by other policies?
- A.
  Accept assignment
- B.
  Assignment of benefits
- C.
  Coordination of benefits
- D.
  Pre-existing condition
Correct Answer
C. Coordination of benefits
Explanation
Coordination of benefits is a group health insurance policy provision that prevents multiple payers from reimbursing benefits provided by other policies. This provision ensures that the total amount reimbursed for a claim does not exceed the actual expenses incurred by the insured individual. It helps to avoid overpayment and potential fraud by coordinating the benefits between different insurance policies and determining the primary and secondary payer for a specific claim.
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11.
The sorting of claims upon submission to collect and verify information about the patient and provider is called claims
- A.
  Adjucation
- B.
  Authorization
- C.
  Processing
- D.
  Submission
Correct Answer
C. Processing
Explanation
The correct answer is processing because it accurately describes the action of sorting claims upon submission to collect and verify information about the patient and provider. Processing involves organizing and reviewing the claims to ensure they meet the necessary criteria and can be further processed for payment or denial.
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12.
Which of the following steps would occur first?
- A.
  Clearing house converts electronic claims into electronic flat file format
- B.
  Clearinghouse verifies claims data and transmits to payers
- C.
  Health insurance specialist batches and submits claims to clearinghouse
- D.
  Health insurance specialist completes electronic or paper based claim
Correct Answer
D. Health insurance specialist completes electronic or paper based claim
Explanation
The health insurance specialist completing the electronic or paper-based claim would occur first because this step needs to be completed before the claim can be submitted to the clearinghouse. Once the claim is completed, it can then be batched and submitted to the clearinghouse for further processing. The clearinghouse will then verify the claims data and convert it into an electronic flat file format before transmitting it to the payers.
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13.
Comparing the claim to payer edits and the patients health plan benefits is part of claims...
- A.
  See Also
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  Adjucation
- B.
  Processing
- C.
  Submission
- D.
  Transmission
Correct Answer
A. Adjucation
Explanation
Comparing the claim to payer edits and the patient's health plan benefits is part of claims adjudication. Adjudication refers to the process of evaluating and determining the validity and payment of a claim based on various factors such as payer policies, patient eligibility, and medical necessity. By comparing the claim to payer edits and the patient's health plan benefits, the adjudication process ensures that the claim meets all the necessary requirements and determines the appropriate payment or denial decision.
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14.
Which describes any procedure or service reported on a claim that is not included
- A.
  Medically unnecessary
- B.
  Non-covered benefit
- C.
  Pre-existing condition
- D.
  Unauthorized service
Correct Answer
B. Non-covered benefit
Explanation
A non-covered benefit refers to any procedure or service that is not included in the coverage provided by an insurance plan. This means that the insurance company will not pay for or reimburse the cost of this particular service. It could be due to various reasons such as the service not being deemed medically necessary, the service being unauthorized or not approved by the insurance company, or the service being related to a pre-existing condition which is not covered by the insurance plan.
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15.
Which is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider?
- A.
  Common data file
- B.
  Encounter form
- C.
  Patient ledger
- D.
  Remittance advice
Correct Answer
A. Common data file
Explanation
A common data file is an abstract of all recent claims filed on each patient, used by the payer to determine whether the patient is receiving concurrent care for the same condition by more than one provider. It serves as a centralized source of information that allows the payer to track and analyze the claims submitted by different providers for the same patient. By reviewing the common data file, the payer can identify any potential duplicate or overlapping services being provided to the patient and make informed decisions regarding payment and coverage.
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16.
Which is the fixed amount patients receive each time they receive health care services?
- A.
  Coinsurance
- B.
  Copayment
- C.
  Deductable
- D.
  Insurance
Correct Answer
B. Copayment
Explanation
A copayment is a fixed amount that patients are required to pay each time they receive health care services. This payment is typically made at the time of service and is a predetermined, fixed cost that the patient is responsible for. It is separate from any deductibles or coinsurance that may also be required. Copayments help to share the cost of care between the patient and the insurance provider, and can vary depending on the specific health plan and the type of service being received.
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17.
Which of the following steps would occur first?
- A.
  Clearinghouse transmits claims data to payers
- B.
  Payer approves claim for payment
- C.
  Payer generates remittance advice
- D.
  Payer performs claims validation
Correct Answer
A. Clearinghouse transmits claims data to payers
Explanation
The clearinghouse transmitting claims data to payers would occur first because it is the initial step in the claims process. The clearinghouse acts as an intermediary between healthcare providers and payers, sending the claims data from the provider to the payer for processing. Once the claims data is transmitted, the payer can then proceed with the subsequent steps such as approving the claim for payment, generating remittance advice, and performing claims validation.
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18.
Which must accept whatever a payer reimburses for procedures or services performed?
- A.
  Nonparticipating provider
- B.
  Out-of-network provider
- C.
  Participating provider
- D.
  Value-added provider
Correct Answer
C. Participating provider
Explanation
A participating provider must accept whatever a payer reimburses for procedures or services performed. This means that they have agreed to a contract with the payer and have agreed to accept the reimbursem*nt rates set by the payer for their services. This is in contrast to nonparticipating providers or out-of-network providers who may not have agreed to these reimbursem*nt rates and may charge the patient additional fees. Value-added provider is not a term used in this context and does not provide a relevant explanation.
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19.
Which is an interpretation of the birthday rule regarding two group health insurance policies when the parents of a child covered on both policies are married to each other and live in the same household?
- A.
  The parent whose birth month and day occurs earlier in the calender year is the primary policy holder
- B.
  The parent who was born first is the primary policy holder
- C.
  Both parents are primary policy holders
- D.
  The parent whose income is higher is the primary policy holder
Correct Answer
A. The parent whose birth month and day occurs earlier in the calender year is the primary policy holder
Explanation
The birthday rule states that if both parents have group health insurance policies and they are married to each other and live in the same household, the parent whose birth month and day occurs earlier in the calendar year is considered the primary policy holder. This means that their insurance policy will be primary and the other parent's policy will be secondary.
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20.
Which is the financial record source document usually generated by a hospital?
- A.
  Chargmaster
- B.
  Day sheet
- C.
  Encounter form
- D.
  Superbill
Correct Answer
A. Chargmaster
Explanation
A chargemaster is a financial record source document that is usually generated by a hospital. It contains a comprehensive list of all the services and procedures provided by the hospital, along with their corresponding charges. The chargemaster is used to bill patients and insurance companies for the services rendered. It ensures accurate and consistent pricing for the hospital's services and helps in maintaining financial records.
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21.
(Refer to figure 4-20 of chapter 4) Which payers claim should be followed up first to obtain reimbursem*nt?
- A.
  Aetna California
- B.
  Blue Cross Blue Shield Florida
- C.
  Home Health Agency
- D.
  Medicaid
Correct Answer
D. Medicaid
Explanation
Medicaid should be followed up first to obtain reimbursem*nt because it is a government-funded program that provides health insurance to low-income individuals. Medicaid typically has stricter guidelines and requirements for reimbursem*nt compared to private insurance companies like Aetna and Blue Cross Blue Shield. Additionally, since Medicaid is a government program, it may take longer to process claims and obtain reimbursem*nt, so it is important to follow up with them first. The Home Health Agency may also need to be followed up with, but Medicaid should be the priority.
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22.
Which protects information collected by consumer reporting agencies?
- A.
  Equal Credit Opportunity Act
- B.
  Fair Credit Reporting Act
- C.
  Fair Dept Collection Practices Act
- D.
  Truth In Lending Act
Correct Answer
D. Truth In Lending Act
Explanation
The Truth In Lending Act is a federal law that aims to protect consumers by requiring lenders to provide clear and accurate information about loan terms and costs. While it primarily focuses on promoting transparency in lending practices, it does indirectly protect the information collected by consumer reporting agencies. This is because the Act requires lenders to disclose certain information, such as the annual percentage rate (APR), which is calculated based on the consumer's credit information obtained from these reporting agencies. Therefore, the Truth In Lending Act indirectly safeguards the accuracy and privacy of consumer credit information.
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23.
Which protects information collected by consumer reporting agencies?
- A.
  Equal Credit Opportunity Act
- B.
  Fair Credit Reporting Act
- C.
  Fair Debt Collection Practices Act
- D.
  Truth In Lending Act
Correct Answer
B. Fair Credit Reporting Act
Explanation
The Fair Credit Reporting Act protects the information collected by consumer reporting agencies. This act ensures that consumer reporting agencies maintain accurate and fair information about individuals and provides individuals with the right to access and dispute any inaccurate information. It also regulates the use of consumer credit information by lenders, employers, and other entities, to prevent discrimination and ensure the privacy and security of consumer data.
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24.
Which is the best way to prevent delinquent claims?
- A.
  Attach supporting medical documentation on claims
- B.
  Enter all claims data in the in the practices suspense file
- C.
  Submit closed claims to all third-party payers
- D.
  Verify all health plan identification information on all patients
Correct Answer
D. Verify all health plan identification information on all patients
Explanation
Verifying all health plan identification information on all patients is the best way to prevent delinquent claims. By ensuring that the health plan identification information is accurate and up-to-date, healthcare providers can avoid claim denials and delays in reimbursem*nt. This step helps to confirm that the patient is eligible for the services being provided and that the claims will be processed correctly by the third-party payers. It is an essential measure to prevent potential issues and ensure smooth claims processing.
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25.
Which is a characteristic of delinquent commercial claims awaiting payer reimbursem*nt?
- A.
  Delinquent claims are outsourced to a collection agency
- B.
  The delinquent claims are resolved directly with the payer
- C.
  The accounts receivable aging report was not submitted
- D.
  The provided remittance notice was delayed by the payer
Correct Answer
A. Delinquent claims are outsourced to a collection agency

Insurance Chapter 4: Prossessing An Insurance Claim (2024)

FAQs

What are the 4 phases of the claim process? ›

The insurance claim life cycle has four phases: adjudication, submission, payment, and processing. It can be difficult to remember what needs to happen at each phase of the insurance claims process.

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What are the steps for processing an insurance claim? ›

Your insurance claim, step-by-step

Connect with your broker. Your broker is your primary contact when it comes to your insurance policy – they should understand your situation and how to proceed. ...
Claim investigation begins. ...
Your policy is reviewed. ...
Damage evaluation is conducted. ...
Payment is arranged.

What is the fourth step in the insurance claim cycle ___________? ›

Step 4: The health insurance benefits and coverage are explained. Your insurance company will send you a letter in the mail called an Explanation of Benefits (EOB). This letter will show you what has been paid, what has been written off by the provider, and what still needs to be paid by you, the patient.

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What is the final step in a claim investigation? ›

At the end of the investigation, an insurer can either reject or accept the insurance claim. Then, an insurance adjuster tables the initial settlement amount.

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What is the first step in processing a claim? ›

File claim.

The first step of the healthcare claims process is submitting a claim, either as a physical copy or digitally. If a hard copy claim is submitted, it must be translated into a digital format.

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What is the first step in any claims settlement process? ›

Collecting information begins the process

As soon as possible after your accident, it's important to begin gathering evidence and information about your accident. This means taking pictures of the scene and damage and keeping copies of all paperwork (police reports, medical records, witness statements, etc.).

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What are the 5 steps to the medical claim process? ›

The Five Vital Steps in Getting a Medical Claim Paid

Patient Demographics. Getting up-to-date patient and insurance information is essential to getting claims paid. ...
Charge Entry. ...
Payment Posting. ...
Working the Accounts Receivables. ...
Sending Monthly Patient Statements.

Mar 22, 2023

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What is a Stage 3 claim? ›

This stage involves obtaining evidence to support the compensation claim, negotiations, and settlement if possible. Stage 3. This is laid out in the Civil Procedure Rules Practice Direction 8B. It involves issuing proceedings, filing evidence at court, and getting a judge to value the claim.

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What are the 3 major types of claims? ›

There are three types of claims: claims of fact, claims of value, and claims of policy. Each type of claim focuses on a different aspect of a topic. To best participate in an argument, it is beneficial to understand the type of claim that is being argued.

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