Insurance practice questions

Answer: A) The parent whose birthday comes first in the year

• ACorrect. The year of birth doesn't matter.
• BIncorrect. The year doesn't matter.
• CIncorrect. Birthday month and day decide.
• DIncorrect. Birthday month and day decide.

Answer: A) The primary care provider's authorization for the patient to see a specialist

In managed care such as an HMO, a referral is the primary care provider's authorization for a patient to see a specialist. It is different from preauthorization, an EOB, and capitation.

• ACorrect. In an HMO, the primary care provider manages the patient's care and refers the patient to specialists. The referral is usually required for the specialist visit to be covered.
• BIncorrect. This is preauthorization (prior authorization). The insurer gives it, not the primary care provider sending the patient to another provider.
• CIncorrect. This is an explanation of benefits (EOB). It is sent after the claim is processed and does not send a patient to another provider.
• DIncorrect. This is capitation, a way of paying providers in managed care. It is not a request for specialty care.

Answer: A) A set amount per patient per month

• ACorrect. Payment doesn't depend on visits.
• BIncorrect. That's fee-for-service.
• CIncorrect. It's a set monthly amount.
• DIncorrect. It covers enrolled patients.

Answer: A) A percentage of the cost

• ACorrect. After the deductible, the patient pays a set percentage.
• BIncorrect. That is a copayment.
• CIncorrect. That is the premium.
• DIncorrect. That is secondary coverage.

Answer: B) File an appeal within the payer's deadline, attaching supporting records

When a claim seems to have been wrongly denied, the office should file a timely appeal with supporting documentation, not resubmit it, bill the patient or write it off.

• AIncorrect. Resubmitting an unchanged claim that has already been denied is usually treated as a duplicate. A denial is challenged through the payer's appeal process.
• BCorrect. The office should request an appeal (for Medicare, a redetermination within 120 days of the notice) and include documentation, such as medical records, showing the denial was wrong.
• CIncorrect. If the office believes the service is covered, billing the patient before using the appeal process is premature and may break payer contract terms.
• DIncorrect. Writing off a claim the office believes was wrongly denied gives up money the practice is owed. Contractual adjustments are for the difference between charges and allowed amounts.

Answer: C) Explain a change

• AIncorrect. This is not its purpose.
• BIncorrect. Diagnoses use ICD-10-CM.
• CCorrect. Modifiers show a service was altered without changing the code.
• DIncorrect. This is demographic.

Answer: B) 65 or older

• AIncorrect. That is CHIP or Medicaid.
• BCorrect. Also some younger people with disabilities or ESRD.
• CIncorrect. That is TRICARE.
• DIncorrect. That is workers' comp.

Answer: A) A clean claim

A clean claim is complete and error-free, so the payer can process it without requesting additional information. Pended, rejected and corrected claims all involve a missing item or an error.

• ACorrect. A clean claim has no defects and can be processed without obtaining additional information from the provider or a third party, so it is usually paid faster.
• BIncorrect. A pended (suspended) claim is held while the payer develops it, often by asking for more information. That is the opposite of this scenario.
• CIncorrect. A rejected claim is returned because of errors or missing data and can't be processed until it is corrected, so it isn't error-free.
• DIncorrect. A corrected (replacement) claim is resubmitted to fix an error on an earlier claim. Nothing here needed fixing.

Answer: A) See out-of-network providers, usually at a higher out-of-pocket cost

A PPO gives patients more freedom: they can see out-of-network providers at a higher cost without a primary care provider or referrals. HMOs, EPOs, and POS plans restrict out-of-network care more.

• ACorrect. PPOs offer both in-network and out-of-network benefits. The patient pays more when using providers outside the network.
• BIncorrect. This describes an HMO. PPO members do not need a primary care provider to manage their care, and they do not need referrals.
• CIncorrect. This describes a plan that requires members to stay in the network, such as an HMO or an EPO. A PPO covers out-of-network care.
• DIncorrect. This describes a point-of-service (POS) plan, which requires a referral to see out-of-network providers. PPOs do not require referrals.

Answer: C) ICD-10-CM

• AIncorrect. This codes supplies and some services.
• BIncorrect. CPT codes procedures.
• CCorrect. ICD-10-CM codes diagnoses.
• DIncorrect. This identifies drugs.