Healthcare Insurance & Claims Processing Flashcards

A claim is denied with remark code CO-4. What does this denial reason indicate?

Answer: The procedure code is inconsistent with the modifier

CO-4 denials indicate that the procedure code submitted is inconsistent with the modifier used on the claim.

Which document serves as the primary source of truth for determining a patient's covered benefits in a commercial insurance plan?

Answer: The Certificate of Coverage or Evidence of Coverage

The Certificate of Coverage (or Evidence of Coverage) is the legally binding document that defines all covered benefits, exclusions, and limitations under a plan.

Under the coordination of benefits (COB) rules, the 'birthday rule' is used to determine which parent's plan is primary for a dependent child. If both parents have the same birthday, which plan is primary?

Answer: The plan of the parent who has been covered longer

When parents share the same birthday, the plan that has been in effect longer is designated as primary under the birthday rule tiebreaker.

A provider submits a claim for 99214 and 99213 for the same patient on the same date of service. The payer rejects the second E/M code. Which rule is being applied?

Answer: Mutually exclusive edit

Payers apply mutually exclusive edits (often via NCCI) to deny two E/M services billed by the same provider for the same patient on the same date.

What is the function of the 'crossover claim' in Medicare/Medicaid dual-eligible billing?

Answer: Medicare automatically forwards the claim to Medicaid after processing for secondary payment

For dual-eligible patients, Medicare processes the claim first and then automatically crossovers the EOB to Medicaid to pay the remaining patient liability.

A healthcare organization receives an 835 transaction from a payer. What does this electronic transaction represent?

Answer: Electronic remittance advice (ERA) containing payment and claim adjudication details

The ANSI X12 835 transaction set is the electronic remittance advice (ERA) that conveys claim payment and adjustment information from payer to provider.

Which type of insurance plan requires members to select a primary care physician (PCP) who must provide referrals to see specialists?

Answer: Health Maintenance Organization (HMO)

HMO plans require members to designate a PCP who acts as the gatekeeper, providing referrals necessary for specialist visits.