Exam 16: Explanation of Benefits and Payment Adjudication

A provider who is able to balance-bill a patient for the amount over the carrier's allowed charge is a(n): A)contracted provider. B)independent provider. C)nonparticipating provider. D)participating provider.

In regard to the RBRVS system, the time it takes to perform a service is considered to be part of the: A)provider's work. B)practice expense. C)time factor. D)staff expense.

A(n) __________ claim is one that has been received by the carrier but cannot be processed due to an error or because additional information is needed.

Prior to the Omnibus Budget Reconciliation Act (OBRA) of 1989, Medicare payments to providers were based on: A)the resources used to perform the procedure or services. B)a Medicare-developed reasonable fee schedule. C)physicians' charge-based fees. D)a capitation arrangement.

If no payment is made on a claim by the carrier because the patient has NOT yet satisfied the deductible: A)an EOB is sent to the patient only. B)an EOB is sent to the provider only. C)an EOB is sent to both the patient and the provider. D)no EOB is sent.

The Medicare conversion factor is updated annually by: A)independent insurance carriers. B)the Centers for Medicare and Medicaid Services (CMS). C)the legislature. D)the Federal Register.

Monies owed to a provider by insurance carriers or patients makes 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: A)medically appropriate. B)usual and ordinary. C)usual, customary, and reasonable. D)average.