Medical Billing Software Medical Billing Software Claims Processing & Denial Management 1 — Questions and Answers
Question 1: Which claim form is used by most non-institutional providers such as physicians and outpatient clinics when submitting paper claims?
- UB-04
- CMS-1500 (Correct answer)
- ADA Dental Claim Form
- HCFA-1450
Correct answer: CMS-1500
The CMS-1500 is the standard paper claim form used by physicians, non-institutional providers, and outpatient facilities to bill Medicare, Medicaid, and most commercial insurers.
Question 2: What is a timely filing limit in medical billing?
- The deadline for a patient to pay their balance
- The payer-established deadline by which a claim must be submitted after the date of service (Correct answer)
- The number of days a provider has to appeal a denied claim
- The time allowed between eligibility verification and service delivery
Correct answer: The payer-established deadline by which a claim must be submitted after the date of service
Timely filing limits are payer-specific deadlines that require claims to be submitted within a set period after the date of service, or the claim will be automatically denied.
Question 3: What does the acronym EDI stand for in medical billing?
- Electronic Diagnosis Index
- Electronic Data Interchange (Correct answer)
- Eligibility Documentation Interface
- Enhanced Denial Investigation
Correct answer: Electronic Data Interchange
EDI (Electronic Data Interchange) is the standardized electronic format used to transmit healthcare claims, remittances, and eligibility transactions between providers and payers.
Question 4: Which HIPAA transaction set is used to submit electronic professional claims to payers?
- 837P (Correct answer)
- 835
- 270/271
- 276/277
Correct answer: 837P
The 837P transaction set is the HIPAA-mandated electronic format for submitting professional (physician) claims to payers.
Question 5: What is the function of modifier -25 in medical billing?
- Indicates a bilateral procedure was performed
- Indicates a significant, separately identifiable evaluation and management service was performed on the same day as a procedure (Correct answer)
- Indicates the service was performed by a physician assistant
- Indicates the claim is being resubmitted after a correction
Correct answer: Indicates a significant, separately identifiable evaluation and management service was performed on the same day as a procedure
Modifier -25 is appended to an E/M code to indicate that a significant, separately identifiable evaluation and management service was rendered by the same physician on the same day as another procedure.
Question 6: Which denial reason code most commonly indicates that a service is not covered under the patient's current plan?
- CO-4
- CO-97
- CO-50 (Correct answer)
- CO-29
Correct answer: CO-50
CO-50 indicates that the billed service is not covered under the patient's current insurance plan, requiring either a patient billing approach or further investigation.
Medical Billing Software Medical Billing Software Claims Processing & Denial Management 1
Which claim form is used by most non-institutional providers such as physicians and outpatient clinics when submitting paper claims?