Medical Claims and Healthcare Coverage Flashcards
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Read the first 7 Medical Claims and Healthcare Coverage flashcards as text
What does 'ICD' stand for in the context of medical billing used in claims processing?
Answer: International Classification of Diseases
ICD (International Classification of Diseases) is the standard worldwide system used by healthcare providers to code diagnoses on medical bills submitted for reimbursement.
What are CPT codes primarily used to identify in medical billing?
Answer: Medical procedures and services performed
CPT (Current Procedural Terminology) codes identify the specific medical procedures and services performed by healthcare providers, telling insurers what was done rather than why.
An Independent Medical Examination (IME) is typically ordered by an insurance adjuster to:
Answer: Obtain an objective assessment of the claimant's medical condition and treatment
An IME provides an independent, objective medical opinion about the nature, extent, and causation of injuries, helping adjusters make informed decisions about claim validity and value.
What is a 'superbill' in medical claims processing?
Answer: A detailed itemized statement of medical services and their billing codes
A superbill is a comprehensive itemized form listing all services provided during a medical visit along with their corresponding diagnosis and procedure codes, used for insurance billing.
Medicare Set-Aside (MSA) arrangements in workers' compensation and liability claims are designed to:
Answer: Protect Medicare's interest by reserving funds for future Medicare-covered medical expenses
MSAs protect Medicare's financial interests by ensuring a portion of settlement funds is set aside to cover future medical expenses related to the injury that Medicare would otherwise pay.
What is the primary purpose of a medical bill audit in claims handling?
Answer: To identify billing errors, duplicate charges, and non-covered services to ensure payment accuracy
Medical bill audits identify overbilling, unbundling, duplicate charges, and non-covered services, ensuring the insurer pays only for legitimate, accurately billed medical care.
Coordination of Benefits (COB) is a process used when:
Answer: A claimant has coverage under more than one health insurance plan
COB establishes how multiple health insurance plans share the cost of a medical claim when a person is covered by more than one plan, preventing duplicate or excessive payments.