Billing, Reimbursement, & Insurance Policies Flashcards
6 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Billing, Reimbursement, & Insurance Policies flashcards as text
Which Medicare claim form is used to submit outpatient hospital facility claims?
Answer: UB-04 (CMS-1450)
The UB-04 (CMS-1450) is the standard claim form used by hospitals and other institutional providers to bill Medicare and most payers for outpatient and inpatient services.
Under the Outpatient Prospective Payment System (OPPS), payment is based on which grouping unit?
Answer: Ambulatory Payment Classification (APC)
OPPS uses Ambulatory Payment Classifications (APCs) to bundle similar outpatient services into a single payment rate for Medicare hospital outpatient claims.
A claim is denied due to a 'coordination of benefits' issue. What does this mean?
Answer: The patient has more than one insurance plan and payer order is disputed
Coordination of benefits (COB) determines which payer is primary and which is secondary when a patient has multiple insurance plans.
What is the purpose of a Remittance Advice (RA)?
Answer: To explain how a claim was processed and what was paid or denied
A Remittance Advice (RA) is sent by the payer to the provider detailing claim adjudication: amounts paid, contractual adjustments, and reason codes for denials.
Which federal law prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals of federal health care program business?
Answer: Anti-Kickback Statute (AKS)
The Anti-Kickback Statute (AKS) makes it a criminal offense to knowingly offer remuneration to induce referrals for services covered by federal health programs.
A patient's claim is returned as 'unprocessable.' What is the most likely reason?
Answer: Required fields such as subscriber ID or NPI are missing or invalid
Unprocessable claims are returned (not denied) because they lack required data elements like a valid NPI, subscriber ID, or date of service, preventing the payer from adjudicating them.