CBCS EXAM 2 QUESTIONS & ANSWERS
2023/2024
Paper Claims - ANSWER-Traditional method used by providers for submissions of charges to insurance
companies
-CMS 1500
-few plans accept encounter forms Medicare will
only accept CMS 1500`
Electronic Claim - ANSWER-Alternative to paper claims submitted to the third-party payer directly by the
physician or through clearinghouse
-paid faster and software has self-editing detects and reports entries may cause to be rejected
Clearinghouse - ANSWER-Entity that recieves transmissions of claims from physicians offices, seperates
claims by carriers and performs software edits to check errors
-once completed claim is sent to proper insurance
-physician pays fee for their services
Universal Claim Form - ANSWER-CMS 1500, became effective July 2007
-All third party payers accept it, Medicare requires all physicians to use it
Claim Form is divided into 2 sections
1. Blocks 1-13=patient info
2.Blocks 14-33=physicians info
Basic Billing and Reimbursment Steps - ANSWER-1.Collect patients info
2.Verifying Insurance
3.Prepare the encounter form
4.Code the diagnosis and procedures
, 5.Review linkage and compliance
6.Calculate physicians charges
7.Prepare Claims
8.Transmit claims
9.payer adjudication
10.Follow up on reimbursement
Life Cycle of Insurance Claims - ANSWER-1.Claims submission-transmission of claims data either
electronically or manually to third party payers or clearinghouse for processing
2.Claims processing- thrid party payers and clearinghouse verify the information found and submitted
claims about the patient and provider
3.Claims adjudication-process by which the claim is compared to payer edits and patients health plan
benefits to verify
-required info is available upon request
-claim is not a duplicate
-payer rules and procedures have been followed
-procedures perfomed or services provided are covered benefits
Non-Covered Benefits - ANSWER-any procedure or service reported on insurance claim that is not listed
in payer's master benefit list
-results in denial
-payers may be able tp recover charges
Unarthorized Benefit - ANSWER-Procedure or services provided without proper authorizationor was not
covered by a current authorization
-denied, provider can't bill patient for charges
Medical Necessity Edit Checks - ANSWER--Procedure codes match the diagnosis codes
-procedure are not elective
-procedures are not exprimental
2023/2024
Paper Claims - ANSWER-Traditional method used by providers for submissions of charges to insurance
companies
-CMS 1500
-few plans accept encounter forms Medicare will
only accept CMS 1500`
Electronic Claim - ANSWER-Alternative to paper claims submitted to the third-party payer directly by the
physician or through clearinghouse
-paid faster and software has self-editing detects and reports entries may cause to be rejected
Clearinghouse - ANSWER-Entity that recieves transmissions of claims from physicians offices, seperates
claims by carriers and performs software edits to check errors
-once completed claim is sent to proper insurance
-physician pays fee for their services
Universal Claim Form - ANSWER-CMS 1500, became effective July 2007
-All third party payers accept it, Medicare requires all physicians to use it
Claim Form is divided into 2 sections
1. Blocks 1-13=patient info
2.Blocks 14-33=physicians info
Basic Billing and Reimbursment Steps - ANSWER-1.Collect patients info
2.Verifying Insurance
3.Prepare the encounter form
4.Code the diagnosis and procedures
, 5.Review linkage and compliance
6.Calculate physicians charges
7.Prepare Claims
8.Transmit claims
9.payer adjudication
10.Follow up on reimbursement
Life Cycle of Insurance Claims - ANSWER-1.Claims submission-transmission of claims data either
electronically or manually to third party payers or clearinghouse for processing
2.Claims processing- thrid party payers and clearinghouse verify the information found and submitted
claims about the patient and provider
3.Claims adjudication-process by which the claim is compared to payer edits and patients health plan
benefits to verify
-required info is available upon request
-claim is not a duplicate
-payer rules and procedures have been followed
-procedures perfomed or services provided are covered benefits
Non-Covered Benefits - ANSWER-any procedure or service reported on insurance claim that is not listed
in payer's master benefit list
-results in denial
-payers may be able tp recover charges
Unarthorized Benefit - ANSWER-Procedure or services provided without proper authorizationor was not
covered by a current authorization
-denied, provider can't bill patient for charges
Medical Necessity Edit Checks - ANSWER--Procedure codes match the diagnosis codes
-procedure are not elective
-procedures are not exprimental
