Healthcare Accounting Billing & Reimbursement Flashcards

A provider submits a claim and receives a denial with Claim Adjustment Reason Code (CARC) 29. What is the most likely issue?

Answer: The claim was not submitted within the required timely filing period

CARC 29 indicates the claim was denied because it was not submitted within the payer's required timely filing limit.

Under the Medicare Outpatient Prospective Payment System (OPPS), payments are determined by which grouping system?

Answer: Ambulatory Payment Classifications (APCs)

OPPS uses Ambulatory Payment Classifications (APCs) to bundle and pay for outpatient hospital services.

What does the term 'superbill' refer to in a physician's office billing workflow?

Answer: A document that captures diagnosis and procedure codes for a patient encounter used to generate a claim

A superbill is an encounter form or charge ticket that lists the diagnosis and procedure codes documented during a patient visit, which is then used to create the billing claim.

Which of the following best describes 'coordination of benefits' (COB)?

Answer: A process that determines the order in which multiple health plans pay a claim to prevent overpayment

COB is the process used when a patient has more than one insurance policy to determine which plan pays first (primary) and which pays second (secondary) to avoid duplicate payments.

In value-based reimbursement, what is a 'shared savings' arrangement?

Answer: A model where providers and payers share in cost savings achieved when spending falls below a benchmark

In shared savings models, if total healthcare costs come in below a pre-set benchmark, the provider organization receives a percentage of the savings as a bonus payment.

A claim has been denied because the procedure requires a referral that was not obtained. Which type of denial is this?

Answer: Technical/administrative denial

A missing referral or prior authorization is an administrative requirement failure, making this a technical or administrative denial.

What is the 'birthday rule' used for in healthcare billing?

Answer: Determining which parent's insurance is primary for a dependent child when both parents have coverage

The birthday rule states that when a child is covered under both parents' plans, the parent whose birthday falls earliest in the calendar year provides the primary insurance.