Reimbursement & Claims Processing Flashcards
7 cards from real CMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Reimbursement & Claims Processing flashcards as text
Which Medicare claim form is used to submit outpatient and professional service claims?
Answer: CMS-1500
The CMS-1500 form is the standard claim form used by non-institutional providers to bill Medicare Part B and most commercial insurers.
What does the term 'coordination of benefits' (COB) refer to in medical billing?
Answer: Managing benefits between two or more insurance plans when a patient has dual coverage
COB is the process of determining which payer is primary and which is secondary when a patient has more than one insurance policy to prevent duplicate payments.
A claim is denied with remark code CO-97. What does this indicate?
Answer: The benefit for this service is included in the payment for another service
CO-97 indicates the service or procedure is not paid separately because it is considered bundled with another service already reimbursed.
Under HIPAA, the standard transaction code set for professional claims is:
Answer: X12 837P
The X12 837P transaction set is the HIPAA-mandated electronic format for submitting professional (physician) claims.
What is the purpose of an Explanation of Benefits (EOB) sent to the patient?
Answer: It explains how the insurance company processed the claim and what, if anything, the patient owes
An EOB details how a claim was processed, including amounts billed, allowed, paid by insurance, and the patient's responsibility—but it is not a bill.
Which of the following best describes 'balance billing'?
Answer: Billing the patient for the difference between the provider's charge and the insurance allowed amount
Balance billing occurs when an out-of-network provider bills the patient for the difference between the charged amount and what insurance paid, which is often prohibited for in-network providers.
What is a 'clean claim' in the context of medical billing?
Answer: A claim free of errors that can be processed without additional information
A clean claim contains all required data elements, has no defects or improprieties, and can be adjudicated without needing additional information from the provider.