Itemized statements if asked must be supplied: by the provider within 30 days or they could be fined $100 per outstanding request. A private organization that contracts with Medicare to pay Part A and some Part B bills is referred to as a, Individuals pay for Medicare Part B coverage through, The term used when Medicare is not responsible for paying first because of coverage under another insurance policy is, When a service or procedure meets Medicare's criteria for coverage, it is said to be, Medicare's fee schedule is based on a system whereby each payment value is found within a range of payments known as, nsurance coverage that is typically primary to Medicare includes all of the following except. An appeal through an Administrative Law Judge (ALJ) Hearing is: What is the notice a doctor or supplier should give a Medicare beneficiary when furnishing an item or service for which Medicare is expected to deny payment? You visit a new Mom & Pop caf that holds weekly drawings for free treats and prizes. Expedited TRICARE appeals must be filed within 3 days of the receipt of the initial denial. CPT code used by a client can impact the type of apppeals done in the client database. Long-term corporate bonds. A payer;s initial review may reject a claim due to _____________. A pending claim is indicated by which claim status category code? How much will his PIP pay. A request for a hearing before an administrative law judge (in a Medicare case) may be made if the amount still in question is ____ or more. \text{20 years} & \text{6.64}\\ A request for a Medicare administrative law judge hearing can be made if the amount in controversy is at least? refusal by a plan to pay for a procedure that does not meet its medical necessity criteria. What is Pearsons cost of common equity? If inadequate payment was received from an insurance company for a complicated procedure, the insurance billing specialist should file a/an _____ on behalf of the physician. Assume that the cost of goods sold is 75% of sales. The process of __________ means verifying the totals on the RA are mathematically correct. If the medical practice receives payment from an insurance company that is more than the contract rate, it is called a/an _____. What is its debt-to-capital ratio? The person filing an appeal is known as a(n) _________, regardless of whether that individual is a provider or patient. Medicare now pays for certain screening procedures in their "Welcome to Medicare" program. funds are available immediately and the transfer is less costly than check deposits. Appeal decisions on Medicare unassigned insurance claims are sent to the patient. payers may deny a claim when outdated procedure codes are used. The third level of Medicare appeals a health care provider may use if they disagree with a claims reconsideration decision. There is standardization of format for the explanation of benefits document for all private insurance carriers. improper or excessive payments resulting from billing errors (mistakenly overpaying a claim or paying twice, postpayment audit finds claim has been paid and should have been denied or downcoded because documentation did not support, may collect a primary payment from Medicare when another payer is primary. Independent contractors that did not take part in the level 1 appeals decision. Requests to the insurance commissioner must be submitted ____. What are the reasons for the focus on standalone risk? The president of Southern Semiconductor Corporation (SSC) made this statement in the companys annual report: SSCs primary goal is to increase the value of our common stockholders equity. Later in the report, the following announcements were made: a. Can the hospital collect from the patient? What is the required rate of return on a stock with a beta of 0.8? insurance carriers' payments of providers' claims. A violation of a Cease and Desist order by the Commissioner under Article 39 carries a monetary penalty of. Revenue is the ____ produced by a health care organization. An insurance claim submitted to an insurance company, for which payment is overdue. What are some ways you could make returning defective merchandise easy for online customers? Tom is injured in his vehicle and sustains $15,000 in medical bills. The Outpatient Code Editor (OCE) is used to: What is the current uniform institutional claim form used for hospitals and facilities for billing procedures and services? Part _____ of Medicare helps pay for charges incurred during an inpatient hospital stay. Public officials who regulate the insurance industry in their state. Pearsons CFO estimates that the companys WACC is 10.50%. Investigate the process for returning defective merchandise by logging on to a large online store. No profits will be produced by the Chinese operation for 4 years, so earnings will be depressed during this period versus what they would have been had the decision been made not to expand in China. This so-called "waiver of liability" applies if a patient did not know, or could not have been expected to know, that Medicare would refuse to pay for the services in question. There are _____ levels to the Medicare appeals process. Guidelines for claims submission, such as which services are covered, and reimbursement rates is dictated by? A listing of outstanding accounts that have not been paid is referred to as ? A _________ occurs when a procedure and diagnosis are not correctly linked, in the opinion of the payer. \text{Term} & \text{Rate}\\ If deductible not met coinsurance is collected and the amount paid is credited toward their deductible. Prior to appealing a claim, the health care provider should determine that there is sufficient information to back up the claim. A qualified independent contractor (QIC) conducts Medicare level 1 appeals. Only unorganized and poorly managed health care organizations will experience claim denials. Which of the following is true for a Federal District Court appeal? c. The company holds about half of its assets in the form of U.S. Treasury bonds, and it keeps these funds available for use in emergencies. A request for re-consideration to an insurance company that denies payment for all or part of a claim. Part _____ of Medicare helps pay for physician and outpatient charges. to a patient on the same date at the same place of service by two or more physicians, Concurrent care is provided ______________. The account aging report which categorizes outstanding claims as current, __, ___, ___, and ___ days, should be generated each month. an insurance policy that will pay a lump-sum benefit to your family or another beneficiary of your choice, if you die while the policy is in effect. Minor errors found by the practice on transmitted claims require which of the following? A document sent by an insurance carrier to the provider of services, detailing services billed and describing payment determination issued. What does the abbreviation of COB stand for? Under a fee-for service or traditional indemnity plan is an one limited to receiving health care from a specific number of doctors or can that person pretty much choose whatever doctor they want? To send another request for payment for an overdue bill to either the insurance company or the patient. The deadline for filing Medicare claims is 1 year after the last date of service. ____________ follow up on claims that are not processed within the specified claim turnaround time for the payer. Which of the following is an example of concurrent care? What is "expedited review" for Medicare Advantage beneficiaries? Discuss how SSCs stockholders might view each of these actions and how the actions might affect the stock price. \text{Stream B} & \text{\$ 0} & \text{\$ 250} & \text{\$ 450} & \text{\$ 450} & \text{\$ 450} & \text{\$ 150}\\ Be sure to consider factors such as shipping costs, packaging materials, insurance issues, and other issues that may arise. Modifiers GU, GA, GX, and EY are examples of: A patient signed an ABN for services that Medicare considered not covered with the diagnosis submitted to Medicare. In addition, consumers can be referred to the "SHIP" or "State health insurance assistance program" in their area. Medicare holds patients harmless in certain circumstances, even if Medicare does not cover the services being disputed. What code indicates an error has occurred in transmission? Which of these HIPAA transactions is sent by a payer to answer a question about a submitted claim? FERA: Fraud Enforcement and Recovery Act of 2009, state insurance commission only filed when there is repeated unresolved problems. The act that provides for a federal system of old age, survivors, disability, and hospital insurance is the. \text{30 years} & \text{6.73}\\ Which of these HIPAA transactions is used by medical offices to ask payers about the status of submitted claims? Medicare Advantage beneficiaries have an additional right to request an "expedited" (within 72 hours) decision when asking for reconsideration. It requires signing up with your email address. Assume that the risk-free rate is 3.5% and the market risk premium is 4%. zero balance. From the payers point of view, ___________ are improper or excessive payments resulting from billing errors for which the provider owes refunds. Any dividend greater than the amount required to buy the one-year term insurance is applied to the policyowner's choice of one of the other four basic dividend options. What will a payer do when a claim is submitted with outdated codes? If the insured dies 5 years after he bought a Life insurance policy and the insurer determines that there was material misrepresentation on his application, they will: The policyowner wishes to provide for the care of her minor child in the event of premature death. \text{5 years} & \text{6.05}\\ The correct method to send documents for a Medicare reconsideration (Level 2) is by ? The patient was informed prior to the test being performed that the laboratory procedure is not covered by Medicare with the patient's diagnosis. c. How many times per year does Zane turn over its inventory? The patient asked the laboratory to submit the bill to Medicare for a denial because the secondary insurance company may pay for the procedure. Medicare patients should not be charged for the primary insurance coinsurance until the RA is received and examined because the patient is entitled to have Medicare pay these charges. On an aging report, which category describes a current invoice? All of these statements concerning the coordination of benefits are true except, Disability Income Policy - Benefit Trigger. The claim turnaround time is stated ____________, An insurance aging report lists __________, An aging report groups claims or bills according to _____________. An inquiry made to an insurance company to locate the status of an insurance claim. LCD's policies outline general provisions for acceptance or rejection of Medicare claims. Medicare Part D covers long-term (nursing home) care. C. RA that covers a batch of processed claims. The "waiver of liability" does not excuse a patient from financial responsibility for services provided under Medicare Part B, if those services were provided by a nonparticipating provider who did not "take assignment" of the claim. A finalized claim is indicated by which claim status category code? If Medicare is the secondary payer, the claim must be submitted using the ___________, The payer's processing of claims is called ___________, A payer's determination means it's going to ____________, A payer's decision regarding to pay, deny, or partially pay a claim is called _____________, lack of eligibility for a reported service, A payer's automated claim edits may result in claim denial because of ____________, A claim that is removed from a payer's automated processing system is sent for ____________, When a claim is pulled by a payer for manual review, the provider may be asked to submit __________, Medical situations in which a patient receives extensive care from two or more providers on the same date of service is called _________, During the adjudication process, if there is a problem during the automated review, the claim is pulled for ___________. minor errors or omissions have been done. The company is spending$500 million to open a new plant and expand operations in China. The patient's health insurance card specifies all benefits and coverages. Even if a company promises not to sell your email address, it is possible for spammers to access the company's computers if they are not secure. Use sales in the numerator to calculate the turnover ratio. Funds that are electronically transferred from a payer are directly deposited in the __________, after a claim is rejected or paid less than the expected amount. It is now January 1, 2016, and you are considering the purchase of an outstanding bond that was issued on January 1, 2014. The process that health care organizations use to track services provided to patients from the time they register to the final payment of associated fees is referred to as ____, A delinquent insurance claim may be easily located by reviewing the ____, An insurance claim that is pending because of the need for additional information is also referred to as being in ____. If patient covered by both Medicare and Medicaid, Medicaid is primary. federally mandated program requiring private payers to be the primary payers for Medicare beneficiaries' claims. A sum of money paid by the insurance company or patient to the provider of service that is more than the account balance or more than the allowed amount. c. What information does this graph tell you? The letter "A" following a beneficiary's Social Security number on the HICN indicates the individual was a wage earner. To accomplish this, the owner should probably designate as beneficiary: What does the Real-Time Adjudication tool not provide. Which of these codes might use to explain a determination? In these situations, the older person is not liable for the costs of the services provided. The third level of appeals for Medicare claims with an Administrative Law Judge must be made within 30 days of receiving the reconsideration officer's decision (Level 2 appeals). Is not a permanent life insurance policy. A company has 1,200 eligible employees for its group life insurance program, and the company pays the total premium. If a patient has additional insurance coverage, after the primary payer's RA has been posted, the next step is ___________. \end{matrix} A submitted claim that does not follow specific third party payer instructions or contains a technical error. Filing a grievance with the state insurance commission requires the ____________ to investigate the complaint. ), Patient Coinsurance with Medicare as secondary. The services or supplies needed to diagnose and treat a medical condition. This rule acts as a further incentive for Medicare enrollees to choose "participating" providers whenever possible. the date of claim transmission and receipt of payment, The claim turnaround time is period between ___________. communication of the resolution of a first appeal for Medicare fee-for service claims. One that is processed by a third party payer but is held in an indeterminate (pending) state. The firms total capital is$110 million and it finances with only debt and common equity. e. Dealer commercial paper. Local Coverage Decisions (LCDs) focus exclusively on whether a service is reasonable and necessary according to the ICD-9 code that corresponds with the CPT code. The process of applying payments to the patient account while writing off all adjustments. \begin{matrix} software feature enabling automatic entry of payments on a remittance advice. What is the yield to maturity at a current market price of (1)$865 and (2) $1,166? The Center is based in Willimantic, Connecticut, with offices also in Washington, D.C. Zane Corporation has an inventory conversion period of 64 days, an average collection period of 28 days, and a payables deferral period of 41 days. \text{10 years} & \text{6.12}\\ In the future, though, SSC plans to shift its emergency funds from Treasury bonds to common stocks. comparison of two numbers to make sure RA checks out mathematically, request for reconsideration of a claim adjudication, person/entity exercising the right to receive benefits. What is the required return for the overall stock market? This simply means that the annuitant has purchased a Deferred Annuity and has the option to pay in whatever amount he chooses, or nothing at all! Participating and nonparticipating providers, classification of accounts receivable by length of time. Its stock price is $12 per share and it has 4.8 million shares outstanding. electronic funds transfer: payments are deposited directly into the practices bank account and is mandatory by ACA. Which of the following statements is true? Explain your reasoning. To bring insurance claim submissions to court when there are disputes about payments. The facility was a participating provider, and the allowed amount was $2,000. a. The document together with the payment voucher that is sent to a physician who has accepted assignment of benefits is referred to as an ? An insurance company may _____ a claim to investigate the details of the claim before paying or denying it. Coverage with Medicare Part C (Medicare Advantage Plans) typically includes both Part A and Part B expenses. $$ How important do you suppose control is for the average stockholder of a firm whose shares are traded on the New York Stock Exchange? However, companies focus as much on stand-alone risk as on market risk. Explain. $$ The levels of the Medicare Appeal in the correct order are: Which HCPCS Level II modifier is used to report that the ABN was signed by the patient? Patient eligibility, time limits for filing claims, preauthorization and/or referral, duplicate dates of service, noncovered services, valid code linkages, bundled codes, medical review, utilization review, and concurrent care. to double check that the totals are accurate and consistent, EFT is the abbreviation for ______________. The caf promises not to share your information with any outside parties, but you start receiving a lot of spam after signing up. Number assigned to a patient by the insurance company, which should match the number on the patient's insurance card. Centers for Medicare and Medicaid Services, Health Insurance Portability and Accountability Act. What kind of code appears on payers electronic reports of progress of transmitted claims in their adjudication process? It has an 8% annual coupon and had a 30-year original maturity. Rather, it is the health services provider who suffers the economic loss, not the patient. Before services in capitated plans can begin, insurance coverage must be . A ___ claim is the refusal of an insurance carrier to honor a request to pay for health care services. medical assistance given to a patient who receives independent care from two or more physicians on the same date. If the response is unfavorable, the beneficiary can still pursue review applying the traditional claims period. What resources exist to help a client with a Medicare appeal, other than the attorney? If you bought this bond, which return would you actually earn? There are five distinct steps in the Medicare appeals process after receiving a Medicare Summary Notice" denying the benefit. A list of claims transmitted and how long they have been in process with the payer is shown in the ____________. time period in which a health plan must process a claim (30 to 60 days), state laws obligating carriers to pay clean claims within a certain time period. The abbreviation for MRN stands for _____________, Medicare's unfavorable response to a request for redetermination. When a client bills with multiple CPT codes and line items are denied for different reasons by the payer, All internal levels of appeals available from the payer have been used, 1. The Center for Medicare Advocacy is a nonprofit organization that may provide advocacy free of charge to consumers appealing Medicare coverage denials. Approximately 50% of individuals pursue appeals on a denied insurance claim. \end{matrix} Insurance companies are regulated by a federal regulatory agency. If an insured is in disagreement with the insurer for settlement of a claim, a suit must begin within ? Tom has a Personal Auto Policy providing PIP coverage with a $1,000 deductible. (2) Reconsideration made within 180 days of receiving redetermination notice (3) Administrative law judge must be more than $130 hearing must be requested within 60 days of receiving reconsideration notice. Which is NOT one of the four basic dividend options? Overpayments from Medicare to providers ____________. The _________ of a claim refers to the payer's decision regarding payment. report grouping unpaid claims transmitted to payers by the length of time they remain due. If an insurance claim has been lost by the insurance carrier, the procedure(s) to follow is to ? must be process "other-than-clean" claims within 45 calendar days of receipt. Kayes Kitchenware has a market/book ratio equal to 1. Assume that either action is feasible. Which statement is true of the insurance commission of the state? The pending indeterminate state of an insurance claim because of an error or the need for additional information. What are the PVs of the streams at a 0% discount rate? Which of these HIPAA transactions is sent by a payer to explain claim payment? (1) Redetermination: by an employee must be made within 120 days of receiving intitial claimanswer comes as a letter called MEDICARE REDETERMINATION NOTICE (MRN) in 60 days and letter is sent to both provider and patient. The Medicare Secondary Payer program coordinates the benefits for patients who have both Medicare and _____________, If a Medicare beneficiary receives treatment by workers compensation, the Medicare plan is __________, If a Medicare beneficiary receives treatment for an accident-related claim, the Medicare plan is __________, If a Medicare beneficiary is employed and covered by the employers' group health plan, the Medicare plan is __________. The highest level of a Medicare redetermination is with an administrative law judge hearing. (100% paid by secondary payer if deductible on Part B has been met. A medical review program is established by a(n) ___________. When is an appeal sent to third party payers? Part _____ of Medicare includes the new Medicare advantage options. The patient agrees to the test, and signs the ABN. Harrimon Industries bonds have 6 years left to maturity. The reason for a claim denial is usually identified on the remittance advice with a reason code that translates to a specific denial description. Hearing in front of an Administrative Law Judge (ALU). In theory, market risk should be the only relevant risk. What is the correct order for the basic steps of a payer's adjudication process? Once a claim has been successfully submitted to an insurance carrier, the next step is to ____ the claim until a response is received from the responsible party and the service has been paid in full. What would the facility bill the patient? The process of identifying and reviewing specific reasons for claim denials, followed by development of a process for appealing denied claims when appropriate. The ____________ verifies the medical necessity of providers' reported procedures. All procedures on the claim are associated with the ABN. There are no requirements regarding the amount of money in controversy for the fourth level of Medicare appeals through the Medicare Appeals Council. What is done by a payer to determine the appropriateness of medical services? initial processing, automated review, manual review, determination, and payment.