Medical Billing Software Medical Billing Software Claims Processing & Denial Management 2

Question 1

What is a Remittance Advice (RA) and what HIPAA transaction set carries it electronically?

Accepted Answer

A payer's payment explanation sent via the 835 transaction

Answer

A Remittance Advice details how a payer processed each claim, including payments, adjustments, and denial reasons, and is transmitted electronically via the HIPAA 835 transaction.

Question 2

In medical billing, what is claim 'bundling' and how does it affect reimbursement?

Accepted Answer

Payer practice of combining two separately billed procedures into one payment at a lower rate

Answer

Bundling occurs when a payer combines two procedures considered components of a single service and pays only the allowable for the primary code, reducing reimbursement.

Question 3

What does coordination of benefits (COB) determine in a claim with multiple payers?

Accepted Answer

The order in which primary and secondary insurers pay and their respective financial responsibilities

Answer

COB rules establish which insurer pays first (primary) and which pays second (secondary), preventing duplicate payments and ensuring correct allocation of costs.

Question 4

Which of the following best describes a 'crossover claim'?

Accepted Answer

A Medicare claim that is automatically forwarded to Medicaid or a Medicare Supplement for secondary payment

Answer

A crossover claim is a Medicare claim that is automatically forwarded to the patient's secondary payer (Medicaid or Medigap) after Medicare has adjudicated it.

Question 5

What is the National Correct Coding Initiative (NCCI) designed to prevent?

Accepted Answer

Incorrect use of procedure code combinations that constitute improper unbundling

Answer

NCCI edits establish code pairs that cannot be billed together because one is considered inclusive of the other, preventing improper unbundling that inflates reimbursement.

Medical Billing Software Practice Test

Medical Billing Software Practice Test

Medical Billing Software Medical Billing Software Claims Processing & Denial Management 2