Reimbursement and Billing Flashcards

Which Medicaid provision allows pregnant women to begin receiving benefits immediately while their full application is still being processed?

Answer: Presumptive Eligibility (PE) Medicaid

Presumptive Eligibility Medicaid allows pregnant women who appear to meet income guidelines to begin receiving prenatal care immediately without waiting for full eligibility determination.

When a claim is denied for 'lack of medical necessity,' what is the most appropriate first step for the billing team?

Answer: Submit a formal appeal with supporting clinical documentation

The correct response to a medical necessity denial is to file an appeal within the payer's defined timeframe, submitting clinical documentation that supports the medical necessity of the service.

Under HIPAA, which electronic transaction set is the standard format for submitting professional healthcare claims to insurance payers?

Answer: 837P (professional claim transaction)

The HIPAA 837P transaction is the standardized electronic format for submitting professional claims, while 837I is used for institutional claims.

A patient has a $2,000 annual deductible and has met $1,600 so far this year. Her OB visit charge is $500. What is her patient responsibility for this visit?

Answer: $400 — the remaining deductible balance

With $400 remaining on the deductible ($2,000 minus $1,600), the first $400 of the $500 charge is applied to the deductible; any coinsurance applies to the remaining $100.

When obstetric care is transferred from one provider to another midway through pregnancy, how should the receiving physician bill for services?

Answer: Bill only for the specific services actually provided by that physician

When care is split between providers, each bills only for services personally rendered; the receiving physician uses antepartum-only codes or appropriate delivery/postpartum codes.

Which term describes the annual cap on a patient's total out-of-pocket costs, after which the insurer covers 100% of covered services for the rest of the plan year?

Answer: Out-of-pocket maximum

The out-of-pocket maximum is the annual limit on a patient's cost-sharing obligations; once reached, the health plan pays 100% of covered services for the remainder of the plan year.

Which of the following best defines a 'clean claim' in medical billing?

Answer: A claim containing all required information that passes edits and can be processed without additional follow-up

A clean claim contains all required data elements, has no errors or missing information, and can be adjudicated and paid without further information from the provider.