FREE NCCT Health Insurance Claim Processing Questions and Answers

Question 1

Which form is used by a physician's office to submit claims for outpatient services?

Accepted Answer

CMS-1500

Answer

The CMS-1500 form is the standard claim form used by physicians and other non-institutional providers to bill Medicare Part B and most other insurance carriers for outpatient services. The UB-04 form is used for institutional claims, such as those from hospitals or skilled nursing facilities.

Question 2

What does the term 'adjudication' refer to in the health insurance claim process?

Accepted Answer

The insurance carrier's process of reviewing a claim and determining payment

Answer

Adjudication is the step where the payer (insurance company) evaluates a submitted claim against the patient's policy benefits, provider contract, and medical necessity. This process determines whether the claim should be paid, denied, or reduced in amount.

Question 3

A patient's insurance requires pre-authorization for an MRI. What is the primary purpose of this process?

Accepted Answer

To obtain approval from the insurance company for a service to be covered

Answer

Pre-authorization, or prior authorization, is a process used by insurance companies to verify that a specific service, prescription, or procedure is medically necessary and covered under the patient's plan. Obtaining this approval beforehand helps prevent claim denials for non-covered services.

Question 4

Which coding system is used to report medical procedures and services performed by physicians?

Accepted Answer

CPT (Current Procedural Terminology)

Answer

The CPT (Current Procedural Terminology) coding system, maintained by the American Medical Association (AMA), is used to describe and report medical, surgical, and diagnostic services. ICD-10-CM is used for diagnoses, and HCPCS Level II is for supplies and non-physician services.

Question 5

A patient receives a document from their insurance company that details how a claim was processed, including the amount paid and the patient's financial responsibility. What is this document called?

Accepted Answer

Explanation of Benefits (EOB)

Answer

An Explanation of Benefits (EOB) is a statement sent from the health insurance company directly to the patient to explain what medical treatments and/or services were paid for on their behalf. A Remittance Advice (RA) is a similar document sent from the payer to the provider.

NCCT - National Center for Competency Testing Practice Test

NCCT - National Center for Competency Testing Practice Test

FREE NCCT Health Insurance Claim Processing Questions and Answers