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
When a Medicare patient has end-stage renal disease (ESRD) and employer group health plan coverage, which payer is primary during the first 30 months?
Answer: The employer group health plan is primary for the first 30 months
For ESRD patients with employer group health plan coverage, the group health plan is primary during a 30-month coordination period before Medicare becomes primary.
A provider submits a claim for a service performed on January 15. Medicare's timely filing limit is 12 months from the date of service. What is the last date the claim can be submitted?
Answer: January 15 of the following year
Medicare requires claims to be submitted within one calendar year (12 months) from the date of service, so a service on January 15 must be filed by January 15 of the following year.
What does NCCI stand for in medical coding and billing?
Answer: National Correct Coding Initiative
NCCI (National Correct Coding Initiative) is a CMS program that promotes correct coding by preventing improper payment of Medicare Part B claims.
Which type of edit would prevent payment for a surgical approach code billed separately from the primary procedure?
Answer: Column 1/Column 2 NCCI edit
Column 1/Column 2 NCCI edits bundle component codes (Column 2) with comprehensive codes (Column 1), preventing separate payment for integral parts of a procedure.
Under the Medicare Physician Fee Schedule, which component of the Resource-Based Relative Value Scale (RBRVS) reflects the overhead costs of running a practice?
Answer: Practice Expense RVU
Practice Expense RVUs account for the overhead costs associated with providing a service, such as staff salaries, supplies, and equipment.
A claim for CPT code 99213 is denied because the provider did not obtain preauthorization. Which CARC best fits this denial?
Answer: CO-197
CO-197 indicates the precertification or authorization was absent or exceeded, meaning the service required prior approval that was not obtained.
What is the primary purpose of a Remittance Advice (RA) sent to a provider?
Answer: To detail how claims were adjudicated and the amounts paid or denied
A Remittance Advice (RA), or Electronic Remittance Advice (ERA) in electronic form, details each claim's adjudication including payments, denials, and adjustments.