Claims Management & Adjudication Flashcards
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Read the first 7 Claims Management & Adjudication flashcards as text
Which National Uniform Claim Committee (NUCC) form is used by professional providers to submit paper claims?
Answer: CMS-1500
The CMS-1500 form is the standard paper claim form used by physicians and other professional providers.
A payer issues an Explanation of Benefits (EOB) showing 'CO-45.' What does this adjustment reason code mean?
Answer: Charges exceed the fee schedule/maximum allowable amount
CO-45 indicates the charge exceeds the contracted fee schedule or maximum allowable, and the difference is a contractual write-off.
When a claim is marked 'pending' during adjudication, what does this typically indicate?
Answer: The payer requires additional information before making a payment determination
A pending status means the payer has suspended the claim awaiting additional information, documentation, or internal review.
What is the purpose of the National Provider Identifier (NPI) on a claim?
Answer: To uniquely identify the healthcare provider submitting or rendering the service
The NPI is a unique 10-digit identifier assigned to healthcare providers under HIPAA for use in standard transactions including claims.
A patient has Medicare as primary and Medicaid as secondary. After Medicare pays, what does Medicaid typically cover?
Answer: The patient's Medicare cost-sharing (copay/deductible) up to the Medicaid allowed amount
Medicaid as secondary payer typically covers cost-sharing amounts left by Medicare, but only up to the Medicaid fee schedule amount.
Which of the following is an example of a 'clean claim'?
Answer: A claim with all required data elements properly completed and no known deficiencies
A clean claim contains all required information and has no deficiencies that would prevent or delay payment processing.
What does 'subrogation' mean in the context of medical claims?
Answer: An insurer's right to recover payment from a third party responsible for the patient's injury
Subrogation allows an insurer that paid a claim to seek reimbursement from the party legally responsible for causing the patient's injury.