Exam 17: Refunds and Appeals

ERISA stands for the: A)Employer Resources Income Security Act. B)Employer Retirement Incentive Savings Act. C)Employee Retirement Incentive Savings Act. D)Employee Retirement Income Security Act.

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(Short Answer)

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Question 1

Correct Answer:

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Employee Retirement Income Security Act.

List three situations in which the carrier may ask for rebilling.

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Question 2

Correct Answer:

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Three situations in which the carrier may ask for rebilling include when the wrong diagnosis codes or procedure codes are submitted; when information is incomplete or missing; and when the charges, units, and costs do NOT total properly.

Providing additional clinical information to an insurance company as part of an attempt to overturn a claim denial is known as submitting a(n): A)appeal. B)audit. C)adjudication. D)reconsideration.

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Question 3

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appeal.

Physicians must file a Medicare appeal with an administrative law judge within: A)30 days. B)60 days. C)90 days. D)120 days.

(Short Answer)

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Question 4

The chronological recording of pertinent facts and observations regarding a patient's health status is known as: A)medical transcription. B)documentation. C)claims processing. D)encounter form completion.

(Short Answer)

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Question 5

According to ERISA, a provider must file an appeal within: A)30 days after denial. B)60 days after denial. C)90 days after denial. D)180 days after denial.

(Short Answer)

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Question 6

What is the difference between subjective information and objective findings?

(Essay)

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Question 7

A(n) __________ is an examination and verification of claims and supporting documentation submitted by a physician or medical facility to a carrier.

(Short Answer)

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Question 8

Benefit plans NOT covered by the Employee Retirement Income Security Act (ERISA) include: A)private employee benefit plans. B)church plans. C)self-funded plans. D)insurance plans offered by employers.

(Short Answer)

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Question 9

If a claim is denied due to services NOT being covered under the insurance policy, the patient cannot be billed for the services.

(True/False)

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Question 10

Simple appeals may be accepted by: A)telephone or fax. B)sending a form letter. C)rebilling the claim. D)sending a copy of pertinent court decisions.

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Question 11

What is SOAP?

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Question 12

According to ERISA, a carrier must provide a decision on an appeal within: A)60 days. B)90 days. C)120 days. D)180 days.

(Short Answer)

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Question 13

If a claim is denied because the carrier does NOT have details about an accident, the appeal can be handled through a telephone call.

(True/False)

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Question 14

Wrongfully keeping an overpayment is illegal and is called: A)conversion. B)retention. C)fraud. D)embezzlement.

(Short Answer)

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Question 15

If a denial is upheld when regulatory information was included in the original appeal, the medical office assistant should appeal to the: A)carrier legal department. B)carrier president. C)Department of Labor. D)Department of Insurance.

(Short Answer)

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Question 16

If a claim is denied as a noncovered service, the medical office specialist should: A)bill the patient. B)write off the entire amount. C)negotiate with the patient for partial payment. D)file an appeal with the insurance carrier.

(Short Answer)

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Question 17

The plan section of the medical record includes the diagnosis made at the time of the encounter or shortly thereafter.

(True/False)

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Question 18

If the services provided are NOT appropriate in light of the diagnosis and the claim is denied, a telephone appeal can resolve the situation.

(True/False)

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Question 19

To take a Medicare appeal to the level of a decision by an administrative law judge, the claim must be for a minimum of: A)$130. B)$150. C)$360. D)$500.

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Question 20

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ERISA stands for the: A)Employer Resources Income Security Act. B)Employer Retirement Incentive Savings Act. C)Employee Retirement Incentive Savings Act. D)Employee Retirement Income Security Act.

List three situations in which the carrier may ask for rebilling.

Providing additional clinical information to an insurance company as part of an attempt to overturn a claim denial is known as submitting a(n): A)appeal. B)audit. C)adjudication. D)reconsideration.

Physicians must file a Medicare appeal with an administrative law judge within: A)30 days. B)60 days. C)90 days. D)120 days.

The chronological recording of pertinent facts and observations regarding a patient's health status is known as: A)medical transcription. B)documentation. C)claims processing. D)encounter form completion.

According to ERISA, a provider must file an appeal within: A)30 days after denial. B)60 days after denial. C)90 days after denial. D)180 days after denial.

What is the difference between subjective information and objective findings?

A(n) __________ is an examination and verification of claims and supporting documentation submitted by a physician or medical facility to a carrier.

Benefit plans NOT covered by the Employee Retirement Income Security Act (ERISA) include: A)private employee benefit plans. B)church plans. C)self-funded plans. D)insurance plans offered by employers.

If a claim is denied due to services NOT being covered under the insurance policy, the patient cannot be billed for the services.

Simple appeals may be accepted by: A)telephone or fax. B)sending a form letter. C)rebilling the claim. D)sending a copy of pertinent court decisions.

What is SOAP?

According to ERISA, a carrier must provide a decision on an appeal within: A)60 days. B)90 days. C)120 days. D)180 days.

If a claim is denied because the carrier does NOT have details about an accident, the appeal can be handled through a telephone call.

Wrongfully keeping an overpayment is illegal and is called: A)conversion. B)retention. C)fraud. D)embezzlement.

If a denial is upheld when regulatory information was included in the original appeal, the medical office assistant should appeal to the: A)carrier legal department. B)carrier president. C)Department of Labor. D)Department of Insurance.

If a claim is denied as a noncovered service, the medical office specialist should: A)bill the patient. B)write off the entire amount. C)negotiate with the patient for partial payment. D)file an appeal with the insurance carrier.

The plan section of the medical record includes the diagnosis made at the time of the encounter or shortly thereafter.

If the services provided are NOT appropriate in light of the diagnosis and the claim is denied, a telephone appeal can resolve the situation.

To take a Medicare appeal to the level of a decision by an administrative law judge, the claim must be for a minimum of: A)$130. B)$150. C)$360. D)$500.

Introduction to Professional Billing and Coding Careers

Understanding Managed Care: Insurance Plans

Understanding Managed Care: Medical Contracts and Ethics

Hipaa: Health Insurance Portability and Accountability Act of 1996

ICD-9-CM Medical Coding

ICD-10-CM Medical Coding

Introduction to Cpt and Place of Service Coding

Coding Procedures and Services

Hcpcs and Coding Compliance

Auditing

Physician Medical Billing

Hospital Medical Billing

Medicare Medical Billing

Medicaid Medical Billing

Tricare Medical Billing

Explanation of Benefits and Payment Adjudication

Workers Compensation

Electronic Medical Claims Processing

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