Exam 15: Keys to Successful Claims Management

What are the basic rules for appealing a claim?

If a health insurance professional discovers an error in a claim that could result,or already has resulted,in inaccurate reimbursement,what should be done?

Appeals generally must be in writing and initiated within ___________ days.

List at least 4 ways for optimizing the billing and claims process.

Services that usually require preauthorization or precertification include:

Correct code initiative edits are the result of the National Correct Coding Initiative.

Insurance companies usually have no time limits for filing appeals.

When a patient signs an assignment of benefits,he or she is authorizing the insurance carrier to send payment directly to the healthcare provider.

If a patient is incapacitated in any way,the health insurance professional is not allowed (by law)to contact the patient's insurer to obtain preauthorization.

A suspension file is a series of files set up alphabetically and labeled according to the number of days since the claim was submitted.

List the six keys to successful claims processing.

If there is a second insurance policy,it is important to check "yes" in Block ____________ on the CMS-1500 form and complete Blocks 9,9a,and 9d.

The type of Medicare coverage dictates the specific appeal filing process.

Only the provider has the right to appeal a rejected claim.

After the patient information form is completed,the health insurance professional should check it over to ensure the information is complete and legible.

To complete the entire claims process,a paper claim normally takes:

It is the patient's responsibility to document nonmedical comments in his or her own health record.

The Medicare program has a multileveled appeal process.How many levels are there?

Providers cannot waive Medicare copayments unless ____________ has been established and documented.

EOBs can be submitted only in electronic format.