Test on Health Insurance and Claims Processing
Health Insurance & Claims Processing: A Student Guide
Test: Health Insurance Billing & Claims, Managed Care & Administration, Health Insurance Careers & Education, Health Insurance History & Policy, Managed Care Policy & Regulation, Managed Care Insurance Programs, Managed Care Finance & Payment Models, Managed Care Delivery & Care Models, ICD-10-CM Overview, ICD-10-CM Reference Resources, ICD-10-CM Disease & Neoplasm Coding, ICD-10-CM Drug & Poisoning Coding, ICD-10-CM External Cause & U Codes, ICD-10-CM Guidelines & Guidance, Medical Coding: Diagnosis & Procedures, Medical Coding: Billing & Reimbursement, Medicare Audits & Recovery, Compliance & Auditing — Coding & DME, Compliance & Auditing — Payment Integrity, Medicare Claims & Coding Edits, Medicare Billing, Coverage & Policy
20 questions
Question 1: Local coverage determinations (LCDs) are developed by CMS to describe circumstances for which Medicare will cover specific procedures, services, or technologies on a national basis.
A. Ano
B. Ne
Explanation: LCDs are determinations made by Medicare administrative contractors (MACs) regarding coverage for items and services not developed as National Coverage Determinations (NCDs). NCDs are developed by CMS for national coverage.
Question 2: According to the study materials, when is an Additional Documentation Request (ADR) initiated?
A. When the Medicare administrative contractor (MAC) reviews submitted claim documentation and determines more information is necessary.
B. Before any claim documentation is submitted by the provider.
C. Only during a postpayment claim review determination.
D. As a routine step for every claim processed by the Medicare administrative contractor.
Explanation: The study materials state that an additional documentation request (ADR) is initiated when the Medicare administrative contractor has reviewed documentation submitted with a claim and then requests additional documentation from the provider when deemed necessary and in accordance with Medicare program manuals.
Question 3: The study materials describe the specific role of the CMS HCPCS workgroup.
A. Ano
B. Ne
Explanation: While 'CMS HCPCS workgroup' is listed as a key term, the study materials do not provide a description of its specific role. They only state that 'CMS creates HCPCS Level II codes', but do not attribute this action directly to the 'CMS HCPCS workgroup'.
Question 4: According to the study materials, which of the following describes a key aspect of routine coding audits and monitoring?
A. They are exclusively performed by outside consulting agencies.
B. Their primary role is to establish new coding guidelines and regulations.
C. They identify coding errors and at-risk coding practices.
D. Benchmarking is used to establish criteria for coding assessment, such as coding error rates.
Explanation: Routine coding audits and monitoring, both internal and external, identify coding errors and at-risk coding practices. Benchmarking is a helpful practice used during audits to establish criteria like coding error rates and coding productivity rates for coding assessment. Audits are not exclusively external, and their primary role is not to establish new guidelines.
Question 5: Editing the charge description master (CDM) primarily leads to an increase in erroneous claims and third-party payer denials.
A. Ano
B. Ne
Explanation: Editing the charge description master (CDM) is an internal control mechanism that impacts reimbursement by eliminating erroneous claims and resultant third-party payer denials, not increasing them.