CMC Reimbursement & Claims Processing 2 — Questions and Answers
Question 1: Which Medicare claim form is used to submit outpatient and professional service claims?
- UB-04
- CMS-1500 (Correct answer)
- ADA Dental Claim Form
- CMS-1450
Correct 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.
Question 2: What does the term 'coordination of benefits' (COB) refer to in medical billing?
- Determining which provider will treat the patient
- Managing benefits between two or more insurance plans when a patient has dual coverage (Correct answer)
- Coordinating prior authorization for services
- Splitting payments between facility and physician
Correct 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.
Question 3: A claim is denied with remark code CO-97. What does this indicate?
- Service was not medically necessary
- The benefit for this service is included in the payment for another service (Correct answer)
- Patient is not eligible on the date of service
- Claim was submitted past the timely filing deadline
Correct 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.
Question 4: Under HIPAA, the standard transaction code set for professional claims is:
- X12 837P (Correct answer)
- X12 835
- X12 270/271
- X12 276/277
Correct answer: X12 837P
The X12 837P transaction set is the HIPAA-mandated electronic format for submitting professional (physician) claims.
Question 5: What is the purpose of an Explanation of Benefits (EOB) sent to the patient?
- It is a bill requesting payment from the patient
- It explains how the insurance company processed the claim and what, if anything, the patient owes (Correct answer)
- It authorizes the provider to perform a specific service
- It certifies the patient's eligibility for coverage
Correct 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.
Question 6: Which of the following best describes 'balance billing'?
- Billing the secondary insurer after primary payment
- Billing the patient for the difference between the provider's charge and the insurance allowed amount (Correct answer)
- Applying the deductible to the patient's account
- Requesting payment reconsideration from the insurer
Correct 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.
Question 7: What is a 'clean claim' in the context of medical billing?
- A claim submitted on white paper rather than electronically
- A claim free of errors that can be processed without additional information (Correct answer)
- A claim submitted within 24 hours of the date of service
- A claim that has been paid in full by the insurer
Correct 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.
CMC Reimbursement & Claims Processing 2
Which Medicare claim form is used to submit outpatient and professional service claims?