Question 1

Under a capitation arrangement, a provider is paid a per-member-per-month (PMPM) fee for all enrolled members:

Accepted Answer

A)  who are seen that month. 
B)  whether or not they are seen that month. 
C)  who are not referred to specialty care that month. 
D)  who are not hospitalized that month. 
A)  who are seen that month. 
B)  whether or not they are seen that month. 
C)  who are not referred to specialty care that month. 
D)  who are not hospitalized that month. B

Question 2

Match the following

-Code shown on an explanation of benefits (EOB) to explain the coverage determination or a denial

Accepted Answer

A)  deductible 
B)  electronic remittance advice (ER
A)  
C)  conversion factor 
D)  coinsurance 
E)  relative value unit
F) reason code
G) adjudication
H) copayment
I) withhold
J) allowed charge 
A)  deductible 
B)  electronic remittance advice (ER
A)  
C)  conversion factor 
D)  coinsurance 
E)  relative value unit
F) reason code
G) adjudication
H) copayment
I) withhold
J) allowed charge F

Question 3

A percentage of a provider's payment that is NOT paid during a contract year but is kept by the health plan to offset additional costs incurred for referrals, hospital admissions, or other covered services is called a:

Accepted Answer

A)  disincentive. 
B)  per-member-per-month (PMPM) fee. 
C)  withdrawal. 
D)  withhold. 
A)  disincentive. 
B)  per-member-per-month (PMPM) fee. 
C)  withdrawal. 
D)  withhold. D

Question 4

Monies owed to a provider by insurance carriers or patients make up the ________.

Accepted Answer

The answer of Monies owed to a provider by insurance...

Question 5

No matter what amount a provider charges for a given service, each third-party payer will establish the amount they will pay based on what is considered:

Accepted Answer

A)  medically appropriate. 
B)  usual and ordinary. 
C)  usual, customary, and reasonable. 
D)  average. 
A)  medically appropriate. 
B)  usual and ordinary. 
C)  usual, customary, and reasonable. 
D)  average.

Question 6

Which are steps for processing reimbursements when an EOB/ERA is received from an insurance carrier?

Accepted Answer

A)  determine any write-offs or adjustments required 
B)  compare the EOB/ERA with the claim filed 
C)  check the accuracy of mathematical calculations 
D)  all of the above 
A)  determine any write-offs or adjustments required 
B)  compare the EOB/ERA with the claim filed 
C)  check the accuracy of mathematical calculations 
D)  all of the above

Question 7

Match the following

-A set amount that the patient must pay at the time of service

Accepted Answer

A)  deductible 
B)  electronic remittance advice (ER
A)  
C)  conversion factor 
D)  coinsurance 
E)  relative value unit
F) reason code
G) adjudication
H) copayment
I) withhold
J) allowed charge 
A)  deductible 
B)  electronic remittance advice (ER
A)  
C)  conversion factor 
D)  coinsurance 
E)  relative value unit
F) reason code
G) adjudication
H) copayment
I) withhold
J) allowed charge

Question 8

A provider's usual charge for a service can be higher, equal to, or lower than the insurance carrier's allowed charge.

Accepted Answer

A) True 
 B)False

Question 9

Medicare conversion factor updates are based on all the following EXCEPT:

Accepted Answer

A)  expenditure target. 
B)  adjustments for budget neutrality. 
C)  the Medicare economic. 
D)  the number of denied claims. 
A)  expenditure target. 
B)  adjustments for budget neutrality. 
C)  the Medicare economic. 
D)  the number of denied claims.

Question 10

Explain how the EOB is used in the coordination of benefits process.

Accepted Answer

A copy of the primary payer's

Question 11

The RBRVS system establishes the nationally uniform relative value of a service based on which three cost elements?

Accepted Answer

A)  The cost of payroll, the cost of supplies, and the cost of liability insurance 
B)  The physician's specialty, the physician's work, and the location of the practice 
C)  The location of the practice, the overhead, and the cost of liability insurance 
D)  The physician's work, the practice expense, and the cost of liability insurance 
A)  The cost of payroll, the cost of supplies, and the cost of liability insurance 
B)  The physician's specialty, the physician's work, and the location of the practice 
C)  The location of the practice, the overhead, and the cost of liability insurance 
D)  The physician's work, the practice expense, and the cost of liability insurance

Question 12

When providers determine what fee to charge by considering what other providers charge for similar services, this method is:

Accepted Answer

A)  charge based. 
B)  research based. 
C)  resource based. 
D)  comparison based. 
A)  charge based. 
B)  research based. 
C)  resource based. 
D)  comparison based.

Question 13

Match the following

-Percentage of the cost of covered services that the policyholder must pay

Accepted Answer

A)  deductible 
B)  electronic remittance advice (ER
A)  
C)  conversion factor 
D)  coinsurance 
E)  relative value unit
F) reason code
G) adjudication
H) copayment
I) withhold
J) allowed charge 
A)  deductible 
B)  electronic remittance advice (ER
A)  
C)  conversion factor 
D)  coinsurance 
E)  relative value unit
F) reason code
G) adjudication
H) copayment
I) withhold
J) allowed charge

Question 14

The difference between the billed amount and the allowed amount for services from a participating provider is:

Accepted Answer

A)  billed to the insurance carrier. 
B)  billed to the patient. 
C)  written off by the provider. 
D)  written off by the insurance carrier. 
A)  billed to the insurance carrier. 
B)  billed to the patient. 
C)  written off by the provider. 
D)  written off by the insurance carrier.

Question 15

After a claim is processed, an explanation of benefits (EOB) is sent to the:

Accepted Answer

A)  provider only. 
B)  patient only. 
C)  provider and the patient. 
D)  carrier's headquarters. 
A)  provider only. 
B)  patient only. 
C)  provider and the patient. 
D)  carrier's headquarters.

Question 16

The two main methods used by providers to determine their fees are:

Accepted Answer

A)  capitation-based and resource-based fee structures. 
B)  profit-based and charge-based fee structures. 
C)  charge-based and resource-based fee structures. 
D)  resource-based and usual-and-customary fee structures. 
A)  capitation-based and resource-based fee structures. 
B)  profit-based and charge-based fee structures. 
C)  charge-based and resource-based fee structures. 
D)  resource-based and usual-and-customary fee structures.

Question 17

Which of the following dictates how long patient records are to be kept and stored?

Accepted Answer

A)  retention schedule 
B)  turnaround time 
C)  record retention 
D)  storage schedule 
A)  retention schedule 
B)  turnaround time 
C)  record retention 
D)  storage schedule

Question 18

Under a managed care contract with a capitation reimbursement method, the provider is paid a PMPM fee for each enrolled member regardless of services provided.

Accepted Answer

A) True 
 B)False

Question 19

If an insurance carrier does NOT reconsider a downcoded claim that has been appealed, the medical office specialist can:

Accepted Answer

A)  request assistance from the state insurance commissioner. 
B)  file a complaint with the Department of Health and Human Services (DHHS). 
C)  file a complaint with the Centers for Medicare and Medicaid Services (CMS). 
D)  bill the patient for the remaining balance. 
A)  request assistance from the state insurance commissioner. 
B)  file a complaint with the Department of Health and Human Services (DHHS). 
C)  file a complaint with the Centers for Medicare and Medicaid Services (CMS). 
D)  bill the patient for the remaining balance.

Question 20

Using the RBRVS system, how does the geographic practice cost index (GPCI) affect provider payments?

Accepted Answer

Twenty-five percent of the physician's w

Under a capitation arrangement, a provider is paid a per-member-per-month (PMPM) fee for all enrolled members:

Match the following -Code shown on an explanation of benefits (EOB) to explain the coverage determination or a denial

A percentage of a provider's payment that is NOT paid during a contract year but is kept by the health plan to offset additional costs incurred for referrals, hospital admissions, or other covered services is called a:

Monies owed to a provider by insurance carriers or patients make up the ________.

No matter what amount a provider charges for a given service, each third-party payer will establish the amount they will pay based on what is considered:

Which are steps for processing reimbursements when an EOB/ERA is received from an insurance carrier?

Match the following -A set amount that the patient must pay at the time of service

A provider's usual charge for a service can be higher, equal to, or lower than the insurance carrier's allowed charge.

Medicare conversion factor updates are based on all the following EXCEPT:

Explain how the EOB is used in the coordination of benefits process.

The RBRVS system establishes the nationally uniform relative value of a service based on which three cost elements?

When providers determine what fee to charge by considering what other providers charge for similar services, this method is:

Match the following -Percentage of the cost of covered services that the policyholder must pay

The difference between the billed amount and the allowed amount for services from a participating provider is:

After a claim is processed, an explanation of benefits (EOB) is sent to the:

The two main methods used by providers to determine their fees are:

Which of the following dictates how long patient records are to be kept and stored?

Under a managed care contract with a capitation reimbursement method, the provider is paid a PMPM fee for each enrolled member regardless of services provided.

If an insurance carrier does NOT reconsider a downcoded claim that has been appealed, the medical office specialist can:

Using the RBRVS system, how does the geographic practice cost index (GPCI) affect provider payments?

Introduction to Professional Billing and Coding Careers

Understanding Managed Care: Insurance Plans

Understanding Managed Care: Medical Contracts and Ethics

Introduction to the Health Insurance Portability and Accountability Act Hipaa

ICD-10 Cm Medical Coding

Introduction to CPT and Place of Coding Services

Coding Procedures and Services

Hcpcs Coding and Compliance

Auditing

Physician Medical Billing

Hospital Medical Billing

Medicare Medical Billing

Medicaid Medical Billing

Tricare Medical Billing

Refunds and Appeals

Workers Compensation

Filters

Exam 15: Explanation of Benefits and Payment Adjudication

Under a capitation arrangement, a provider is paid a per-member-per-month (PMPM) fee for all enrolled members:

Match the following -Code shown on an explanation of benefits (EOB) to explain the coverage determination or a denial

A percentage of a provider's payment that is NOT paid during a contract year but is kept by the health plan to offset additional costs incurred for referrals, hospital admissions, or other covered services is called a:

Monies owed to a provider by insurance carriers or patients make up the ________.

No matter what amount a provider charges for a given service, each third-party payer will establish the amount they will pay based on what is considered:

Which are steps for processing reimbursements when an EOB/ERA is received from an insurance carrier?

Match the following -A set amount that the patient must pay at the time of service

A provider's usual charge for a service can be higher, equal to, or lower than the insurance carrier's allowed charge.

Medicare conversion factor updates are based on all the following EXCEPT:

Explain how the EOB is used in the coordination of benefits process.

The RBRVS system establishes the nationally uniform relative value of a service based on which three cost elements?

When providers determine what fee to charge by considering what other providers charge for similar services, this method is:

Match the following -Percentage of the cost of covered services that the policyholder must pay

The difference between the billed amount and the allowed amount for services from a participating provider is:

After a claim is processed, an explanation of benefits (EOB) is sent to the:

The two main methods used by providers to determine their fees are:

Which of the following dictates how long patient records are to be kept and stored?

Under a managed care contract with a capitation reimbursement method, the provider is paid a PMPM fee for each enrolled member regardless of services provided.

If an insurance carrier does NOT reconsider a downcoded claim that has been appealed, the medical office specialist can:

Using the RBRVS system, how does the geographic practice cost index (GPCI) affect provider payments?

Introduction to Professional Billing and Coding Careers

Understanding Managed Care: Insurance Plans

Understanding Managed Care: Medical Contracts and Ethics

Introduction to the Health Insurance Portability and Accountability Act Hipaa

ICD-10 Cm Medical Coding

Introduction to CPT and Place of Coding Services

Coding Procedures and Services

Hcpcs Coding and Compliance

Auditing

Physician Medical Billing

Hospital Medical Billing

Medicare Medical Billing

Medicaid Medical Billing

Tricare Medical Billing

Refunds and Appeals

Workers Compensation

Filters