CEHRS Revenue Cycle and Billing 3 — Questions and Answers
Question 1: Which claim form is used to bill outpatient and professional services to Medicare?
- UB-04
- CMS-1500 (Correct answer)
- ADA Dental Claim Form
- HCFA-1450
Correct answer: CMS-1500
The CMS-1500 (also called HCFA-1500) is used by physicians and other non-institutional providers to bill Medicare and most other payers.
Question 2: A provider writes off the difference between billed charges and the insurance-allowed amount. This is called a:
- Contractual adjustment (Correct answer)
- Bad debt write-off
- Courtesy discount
- Small balance write-off
Correct answer: Contractual adjustment
A contractual adjustment reflects the difference between a provider's billed charges and the contracted allowed amount, which cannot be billed to the patient.
Question 3: The National Provider Identifier (NPI) is a:
- 10-digit numeric identifier assigned to healthcare providers (Correct answer)
- State-issued license number for physicians
- Tax identification number used for billing
- Code identifying the type of insurance plan
Correct answer: 10-digit numeric identifier assigned to healthcare providers
The NPI is a standard, unique 10-digit identification number issued by CMS to covered healthcare providers under HIPAA.
Question 4: Which modifier is appended to a CPT code to indicate that a procedure was performed bilaterally?
- -51
- -50 (Correct answer)
- -59
- -25
Correct answer: -50
Modifier -50 indicates that a procedure was performed bilaterally (on both sides of the body) during the same operative session.
Question 5: The term 'clean claim' refers to a claim that:
- Has been paid in full by the payer
- Contains all required information and no errors requiring follow-up (Correct answer)
- Has been submitted electronically
- Was denied and subsequently corrected
Correct answer: Contains all required information and no errors requiring follow-up
A clean claim is one that is complete, accurate, and can be processed and paid without additional information or correction.
Question 6: Under HIPAA, the standard transaction for transmitting claim payment and remittance information is:
- X12 837P
- X12 835 (Correct answer)
- X12 270/271
- X12 278
Correct answer: X12 835
The X12 835 transaction set is the HIPAA-standard electronic remittance advice (ERA) used to transmit claim payment and explanation of benefits data.
Question 7: When a provider fails to submit a claim within the payer's required timeframe, the claim may be denied for:
- Lack of medical necessity
- Timely filing (Correct answer)
- Duplicate billing
- Coordination of benefits
Correct answer: Timely filing
Timely filing denials occur when claims are not submitted within the payer's specified deadline, which varies by payer and plan type.
CEHRS Revenue Cycle and Billing 3
Which claim form is used to bill outpatient and professional services to Medicare?