Medical Office Administration and Billing Flashcards

What is the purpose of an Explanation of Benefits (EOB) document?

Answer: A statement from the insurance company explaining what was paid, denied, or applied to deductible

An EOB explains how the insurance company processed a claim, including amounts paid, adjustments, patient responsibility, and denial reasons.

What coding system is used to classify diagnoses in medical billing?

Answer: ICD-10-CM codes

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) codes are used to classify and report diagnoses on medical claims.

What is a copayment in health insurance?

Answer: A fixed dollar amount the patient pays at the time of service

A copayment (copay) is a fixed dollar amount paid by the patient at the time of service, regardless of the total cost of care.

Which form is used to submit claims to Medicare for professional services?

Answer: CMS-1500 form

The CMS-1500 is the standard claim form used by individual providers and outpatient facilities to bill Medicare, Medicaid, and many private insurers.

What does 'prior authorization' mean in medical billing?

Answer: Approval from the insurance company before certain services are provided

Prior authorization is pre-approval from the insurance payer confirming that a specific service, medication, or procedure will be covered before it is performed.

What is the difference between a deductible and coinsurance?

Answer: A deductible is the amount paid before insurance begins; coinsurance is the percentage paid after the deductible is met

The deductible is the annual out-of-pocket amount before insurance pays; coinsurance is the percentage of costs shared between patient and insurer after the deductible.