CCA Medical Claims and Healthcare Coverage 2

Question 1

What does 'reasonable and customary' refer to in medical claims evaluation?

Accepted Answer

The typical range of fees charged for a service in a specific geographic area

Answer

Reasonable and customary (R&C) represents the prevailing fees charged for specific medical services in a particular geographic area, used as a benchmark to assess whether charges are appropriate.

Question 2

Under HIPAA regulations, a claims adjuster can obtain a claimant's medical records:

Accepted Answer

With the claimant's written authorization or a valid legal process such as a subpoena

Answer

HIPAA requires a valid patient authorization or legal process such as a subpoena for the release of protected health information to third parties including insurance adjusters.

Question 3

A 'peer review' in medical claims handling involves:

Accepted Answer

A qualified medical professional evaluating the appropriateness of another physician's treatment

Answer

Peer review involves a qualified medical professional assessing whether the treatment provided was medically necessary, appropriate for the diagnosis, and consistent with accepted clinical standards.

Question 4

What is a medical lien in personal injury claims?

Accepted Answer

A healthcare provider's legal right to share in settlement proceeds for unpaid medical bills

Answer

A medical lien gives healthcare providers who treated an injury victim the legal right to be reimbursed from any settlement or judgment the patient receives for their injuries.

Question 5

What is the significance of establishing 'causation' when evaluating a medical claim?

Accepted Answer

It establishes the connection between the incident and the claimant's medical condition or injury

Answer

Causation establishes whether the claimant's injury or medical condition was caused by or directly related to the insured incident, which is fundamental to determining coverage and liability.

(CCA) Certified Claims Adjuster Practice Test

(CCA) Certified Claims Adjuster Practice Test

CCA Medical Claims and Healthcare Coverage 2