CEHRS Revenue Cycle and Billing 5 — Questions and Answers
Question 1: A payer denies a claim stating the service is 'not covered under the patient's plan.' The best next step is to:
- Write off the balance immediately
- Send the patient a bill for the full amount
- File an appeal with clinical documentation supporting the service (Correct answer)
- Resubmit the same claim without changes
Correct answer: File an appeal with clinical documentation supporting the service
Non-covered service denials can sometimes be overturned on appeal with supporting clinical documentation demonstrating medical necessity or plan coverage.
Question 2: Which type of health plan requires patients to select a primary care physician (PCP) and obtain referrals to see specialists?
- Preferred Provider Organization (PPO)
- Health Maintenance Organization (HMO) (Correct answer)
- Exclusive Provider Organization (EPO)
- High Deductible Health Plan (HDHP)
Correct answer: Health Maintenance Organization (HMO)
HMOs require members to choose a PCP who coordinates their care and provides referrals to in-network specialists.
Question 3: Under the CMS-1500 claim form, Box 21 is used to report:
- CPT procedure codes
- ICD diagnosis codes (Correct answer)
- The rendering provider's NPI
- The date of service
Correct answer: ICD diagnosis codes
Box 21 of the CMS-1500 requires the ICD-10-CM diagnosis codes that support the medical necessity of the billed services.
Question 4: A Medicare patient sees a non-participating provider who does not accept assignment. The provider's charge is $300 but Medicare's allowed amount is $200. The maximum the provider can bill the patient above the Medicare allowed amount is limited by:
- The patient's co-insurance
- The limiting charge regulation (Correct answer)
- The patient's deductible balance
- The payer's contractual adjustment
Correct answer: The limiting charge regulation
The Medicare limiting charge caps the amount a non-participating provider may bill a Medicare beneficiary at 115% of the non-participating fee schedule amount.
Question 5: Which of the following is an example of 'unbundling' in medical billing?
- Reporting a comprehensive procedure code when only components were performed
- Billing each component of a surgical package separately instead of using the global code (Correct answer)
- Submitting the same claim to two different payers
- Adding a modifier to indicate a reduced service
Correct answer: Billing each component of a surgical package separately instead of using the global code
Unbundling is the improper practice of billing multiple procedure codes for components that should be reported under a single comprehensive code.
Question 6: The Medicare Secondary Payer (MSP) rules determine that Medicare pays secondary when a patient is covered by employer group health insurance and the employer has:
- Fewer than 20 employees
- 20 or more employees (Correct answer)
- Only part-time employees
- A self-funded plan
Correct answer: 20 or more employees
MSP rules require that employer group health plans are primary to Medicare when the employer has 20 or more employees.
Question 7: A practice's first-pass claim acceptance rate is 78%. This means:
- 78% of patients paid their co-pays at time of service
- 78% of submitted claims were paid without rejection or denial on initial submission (Correct answer)
- 78% of denied claims were successfully appealed
- 78% of charges were collected within 30 days
Correct answer: 78% of submitted claims were paid without rejection or denial on initial submission
First-pass acceptance rate measures the percentage of claims accepted and paid by payers on the initial submission without needing correction or resubmission.
CEHRS Revenue Cycle and Billing 5
A payer denies a claim stating the service is 'not covered under the patient's plan.' The best next step is to: