CMC Reimbursement & Claims Processing 2

Question 1

Which Medicare claim form is used to submit outpatient and professional service claims?

Accepted Answer

CMS-1500

Answer

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?

Accepted Answer

Managing benefits between two or more insurance plans when a patient has dual coverage

Answer

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?

Accepted Answer

The benefit for this service is included in the payment for another service

Answer

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:

Accepted Answer

X12 837P

Answer

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?

Accepted Answer

It explains how the insurance company processed the claim and what, if anything, the patient owes

Answer

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.

(CMC) Certified Medical Coder Practice Test

(CMC) Certified Medical Coder Practice Test

CMC Reimbursement & Claims Processing 2