Exam 16: Explanation of Benefits and Payment Adjudication

What information is found on the explanation of benefits (EOB)?

The section of the explanation of benefits (EOB) that summarizes the total deductions, charges NOT covered by the plan, and the amount the patient may owe the provider is the: A)service information. B)coverage determination. C)benefit payment information. D)summary information.

Which three factors are considered in determining resource-based fee structures?

Claims processing involves the verification of medical necessity for the reported procedures; this task is performed by: A)medical office specialists. B)medical directors. C)medical review examiners. D)automated claims processors.

A provider is paid a per-member-per-month (PMPM) fee for each enrolled member in a health plan that uses the __________ method of reimbursement.

Medical necessity reduction by an insurance carrier is also known as __________ .

Participating providers can demand payment in full from the patient rather than waiting for the insurance carrier to process the claim.

A claim that is removed from a payer's automated processing system for additional review is subject to: A)preauthorization. B)manual review. C)medical-necessity examination. D)claims edit.

A patient is expected to pay for services excluded from his or her insurance policy at the time the service is rendered.

The patient is responsible for the difference between the provider's usual charge and the carrier's allowed charge when services are received from a participating provider.

A positive or negative change to a patient's account balance is a(n) __________ .

The difference between the billed amount and the allowed amount for services from a participating provider is: A)billed to the insurance carrier. B)billed to the patient. C)written off by the provider. D)written off by the insurance carrier.

What forms of identification should be requested to verify a patient's identity?

The physician's work element accounts for what percentage of the total relative value for each service? A)25% B)32% C)52% D)75%

Under an 80/20 plan, if a nonparticipating provider's usual charge is $200 for a procedure and the allowed amount is $150, the provider can collect: A)$150 from the insurance carrier and $50 from the patient. B)$120 from the insurance carrier and $30 from the patient. C)$120 from the insurance carrier and $80 from the patient. D)$160 from the insurance carrier and $40 from the patient.

During the patient's care, all procedures and tests are documented on the: A)encounter form. B)explanation of benefits. C)claim form. D)registration form.

The notification sent by the insurance carrier to the patient and provider after a claim has been processed is known as a(n): A)patient registration form. B)encounter form. C)charge slip. D)explanation of benefits.

A lockbox service provided by a bank helps control receivables by collecting and depositing carrier and patient payments faster than if the process were performed by office staff.

In regard to the RBRVS system, the technical skill of the provider is considered to be part of the: A)provider's work. B)practice expense. C)provider's training. D)malpractice risk.

What percentage of a physician's work value is adjusted based on geographic cost differences? A)25% B)45% C)55% D)75%