NHA CBCS Chapter 2 - Claims Processing Questions and Answers (2024 / 2025) (Verified Answers)
Medicare
Federally funded health insurance provided to people age 65 or older, people younger than 65 who have certain disabilities, and people of all ages with end stage kidney disease. Funded and admin...
NHA CBCS Chapter 2 - Claims Processing Questions
and Answers () (Verified Answers)
Medicare
Federally funded health insurance provided to people age 65 or older, people younger than 65 who
have certain disabilities, and people of all ages with end stage kidney disease. Funded and
administered at the national level.
Medicaid
A government based health insurance option that pays for medical assistance for individuals who
have low incomes and limited financial resources. Funded at the state and national level.
Administered at the state level. (LAST RESORT BILLING)
CMS-1500
Specific form that providers must fill out to bill Medicare required by ASCA.
- Revised by NUCC
- New forms must be approved by the White House Office of Management & Budget (OMB)
NPI
National Provider Identifier. A unique 10-digit code for providers required by HIPAA.
HMOs
Health Maintenance Organization
Plan: Allows patients to only go to physicians, other healthcare professionals, or hospitals on a list of
approved providers, except in an emergency
Procedure Code
ICD-9-CM, CPT, HCPCS codes that represents the procedure or service provided.
Modifier
Additional information about types of services; part of valid CPT or HCPCS code.
Timely Filing Requirement
Within one calendar year of the claims date of service.
Coordination of Benefits
Determines which insurance plan is primary in which is secondary.
Explanation of Benefits (EOB)
Describes the services rendered, payment covered, benefit limits, and denials.
Crossover Claims
Claim submitted by people covered by a primary and secondary insurance plan, such as Medicare and
Medicaid. Medicare received the bill first, applies a deductible/coinsurance and then automatically
forwards it to Medicaid. providers no longer have to bill Medicaid separately for the Medicare
deductible, coinsurance, or co-pay amount.
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