CMS Medicare Specialist Claims Processing & Billing Procedures 2

Question 1

Which Medicare claim form is used by institutional providers such as hospitals and skilled nursing facilities?

Accepted Answer

UB-04 (CMS-1450)

Answer

The UB-04 (CMS-1450) is the standard institutional claim form used by hospitals, SNFs, and other facility-based providers.

Question 2

A Medicare claim is returned to a provider as 'unprocessable' (RTP). What is the primary distinction between an RTP and a claim denial?

Accepted Answer

An RTP means the claim was never processed and must be corrected and resubmitted, while a denial has been adjudicated

Answer

An RTP (Return to Provider) means the claim lacked required data and was never entered into processing; it must be corrected and resubmitted, unlike a denied claim which has been adjudicated.

Question 3

Under Medicare Secondary Payer (MSP) rules, when a patient has both Medicare and an employer group health plan (EGHP) and the employer has 20+ employees, which pays primary?

Accepted Answer

The EGHP pays primary and Medicare pays secondary

Answer

For working aged beneficiaries whose employer has 20 or more employees, the EGHP is primary and Medicare is secondary under MSP rules.

Question 4

What is the timely filing deadline for initial Medicare Part B claims submitted by participating providers?

Accepted Answer

1 year from date of service

Answer

Medicare requires initial claims to be filed within one calendar year (12 months) from the date of service.

Question 5

A provider submits a claim with diagnosis code Z00.00 as the primary diagnosis for a Medicare patient receiving chemotherapy. What issue does this present?

Accepted Answer

The primary diagnosis should reflect the condition being treated (e.g., the cancer), not a routine exam code

Answer

For active treatment services like chemotherapy, the primary diagnosis should be the condition being treated (the malignancy), not a general encounter/routine exam code.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Medicare Specialist Claims Processing & Billing Procedures 2