Healthcare Insurance & Claims Processing Flashcards

A payer issues a recoupment demand after identifying an overpayment made two years ago. Under Medicare, what is the standard lookback period for overpayment recovery?

Answer: 5 years

Under the Affordable Care Act, Medicare's overpayment lookback period is 6 years; however, the practical administrative standard often cited in compliance contexts is 5 years.

Which HCPCS Level II modifier is appended to a claim to indicate that a service was rendered by a nurse practitioner (NP) in collaboration with a physician?

Answer: -SA

HCPCS modifier SA indicates that the service was provided by a nurse practitioner with physician supervision, which is required by some payers for proper reimbursement.

What distinguishes a 'carve-out' benefit from standard plan coverage?

Answer: A carve-out separates a specific benefit, such as behavioral health, and manages it through a different entity or contract

A carve-out separates administration and reimbursement of a specific benefit category (e.g., behavioral health, pharmacy, vision) from the main health plan, often managed by a specialty company.

Under the No Surprises Act, which type of provider is primarily restricted from issuing surprise bills to patients for out-of-network emergency services?

Answer: Non-participating (out-of-network) providers at in-network facilities and emergency settings

The No Surprises Act restricts out-of-network providers from billing patients more than in-network cost-sharing amounts for emergency services and certain non-emergency services at in-network facilities.

A payer uses a 'usual, customary, and reasonable' (UCR) fee schedule. What does this method base reimbursement on?

Answer: The prevailing fees charged by providers in the same geographic area for similar services

UCR rates are derived from databases of actual charges submitted by providers in a geographic region, representing what is considered 'usual' for that market.

What is the primary purpose of a remittance advice remark code (RARC) on an EOB?

Answer: To provide supplemental information explaining a claim adjustment or denial reason

RARCs provide additional detail and context beyond the claim adjustment reason code (CARC), explaining why a payment adjustment was made.

A healthcare provider receives payment less than expected. Upon reviewing the 835 ERA, they find adjustment group code 'PR.' What does PR indicate?

Answer: The adjustment is the patient's responsibility (deductible, copay, coinsurance)

The PR (Patient Responsibility) group code on an 835 transaction indicates amounts that the patient is responsible for, such as deductibles, copayments, and coinsurance.