NHA CBCS ACTUAL FINALS ANSWERS AND
QUESTIONS SET A+
✔✔Usual Customary and Reasonable - ✔✔refer to the base amount that is treated as
the standard or most common charge for a particular medical service when rendered in
a particular geographic area.
✔✔Relative Value Payment Method - ✔✔The payment amount for each service paid
under the physician fee schedule is the product of three factors; a nationally uniform
relative value for service; a geographic adjustment factor (GAF); a nationally uniform
conversion factor for the service.
✔✔Medicare Resource Based Relative Value Unit (RVU) Payments/Components -
✔✔The schedule assigns certain values to procedures/costs based upon Total RVUs.
The total consists of three components; work, practice expense, and malpractice.
Medicare adjusts payment by geographic price cost index (GPCI) and pays depending
on locale.
✔✔Clean Claim - ✔✔A completed insurance claim form submitted with the program
time limit that contains all the necessary information without deficiencies so it can be
processed and paid promptly.
✔✔Dirty Claim - ✔✔A claim submitted with errors or one that requires manual
processing to resolve problems or is rejected for payment.
✔✔Invalid Claim - ✔✔Any Medicare claim that contains complete, necessary
information but is illogical or incorrect (e.g., listing an incorrect provider number for a
referring physician). Invalid claims re identified to the provider and may be resubmitted
✔✔Rejected Claim - ✔✔A rejected claim is an electronically submitted claim that is
unprocessable due to missing or invalid information required by the payer.
, ✔✔ABN / Advance Beneficiary Notice - ✔✔a notice that a doctor, supplier, or provider
gives a Medicare beneficiary before furnishing an item or service if the doctor, supplier,
or provider believes that Medicare may deny payment.
✔✔Paper Claims /CMS 1500 - ✔✔An insurance claim submitted on paper, including
those opticaly scanned and converted to an electronic form by the insurance carrier
✔✔Electronic Claim - ✔✔An insurance claim submitted to the insurance carrier via a
central processing unit (CPU), tape, diskette, direct data entry, direct wire, dial-in
telephone, digital fax, or personal computer download or upload
✔✔CMS 1500 Universal Claim Form - ✔✔Developed by the AMA and the Centers for
Medicare and Medicaid Services (CMS). Used by physicians and other professionals to
bill outpatient services and supplies to Tricare, Medicare, some Medicaid programs, and
some private insurance/managed care plans
✔✔Basic Billing Reimbursement Steps - ✔✔Patient Info, Verify Ins. Prepare encounter
form, Code DX & CPT, Review Linkage Protocol, Calculate physicians charges,
Prepare claim, Transmit claim, Follow up on Reimbursement.
✔✔Review Linkage Protocol - ✔✔Appropriateness of Codes, Payers rules about
linkage, Documentation to support codes, Compliance with regulation and guidelines
✔✔Life Cycle of a Claim - ✔✔Submission, Processing, Adjudication, Non-covered,
Unauthorized, Medical Necessity Checks, Payment / RA / ERA
✔✔What does MAC stand for? - ✔✔Medicare Administrative Contractor
✔✔"A condition that develops after, the outpatient care has been provided or during an
inpatient admission." - ✔✔Complication
✔✔"A concurrent condition that coexists with the first-listed diagnosis or principal
diagnosis, has potential to affect treatment of the aforementioned diagnosis and is an
active condition for which the patient is treated and/or monitored." - ✔✔Comorbidity
✔✔The process by which the provider contacts the insurance carrier to see if the
proposed procedure is covered by a specific patients insurance policy. -
✔✔Preauthorization
✔✔Monies or Funds that are owed to the practice for services provided - ✔✔Accounts
Receivable (A/R)
✔✔Monies being paid from the medical practice, for instance to pay for supplies, rent,
utilities, payroll, etc. - ✔✔Accounts Payable (A/P)
QUESTIONS SET A+
✔✔Usual Customary and Reasonable - ✔✔refer to the base amount that is treated as
the standard or most common charge for a particular medical service when rendered in
a particular geographic area.
✔✔Relative Value Payment Method - ✔✔The payment amount for each service paid
under the physician fee schedule is the product of three factors; a nationally uniform
relative value for service; a geographic adjustment factor (GAF); a nationally uniform
conversion factor for the service.
✔✔Medicare Resource Based Relative Value Unit (RVU) Payments/Components -
✔✔The schedule assigns certain values to procedures/costs based upon Total RVUs.
The total consists of three components; work, practice expense, and malpractice.
Medicare adjusts payment by geographic price cost index (GPCI) and pays depending
on locale.
✔✔Clean Claim - ✔✔A completed insurance claim form submitted with the program
time limit that contains all the necessary information without deficiencies so it can be
processed and paid promptly.
✔✔Dirty Claim - ✔✔A claim submitted with errors or one that requires manual
processing to resolve problems or is rejected for payment.
✔✔Invalid Claim - ✔✔Any Medicare claim that contains complete, necessary
information but is illogical or incorrect (e.g., listing an incorrect provider number for a
referring physician). Invalid claims re identified to the provider and may be resubmitted
✔✔Rejected Claim - ✔✔A rejected claim is an electronically submitted claim that is
unprocessable due to missing or invalid information required by the payer.
, ✔✔ABN / Advance Beneficiary Notice - ✔✔a notice that a doctor, supplier, or provider
gives a Medicare beneficiary before furnishing an item or service if the doctor, supplier,
or provider believes that Medicare may deny payment.
✔✔Paper Claims /CMS 1500 - ✔✔An insurance claim submitted on paper, including
those opticaly scanned and converted to an electronic form by the insurance carrier
✔✔Electronic Claim - ✔✔An insurance claim submitted to the insurance carrier via a
central processing unit (CPU), tape, diskette, direct data entry, direct wire, dial-in
telephone, digital fax, or personal computer download or upload
✔✔CMS 1500 Universal Claim Form - ✔✔Developed by the AMA and the Centers for
Medicare and Medicaid Services (CMS). Used by physicians and other professionals to
bill outpatient services and supplies to Tricare, Medicare, some Medicaid programs, and
some private insurance/managed care plans
✔✔Basic Billing Reimbursement Steps - ✔✔Patient Info, Verify Ins. Prepare encounter
form, Code DX & CPT, Review Linkage Protocol, Calculate physicians charges,
Prepare claim, Transmit claim, Follow up on Reimbursement.
✔✔Review Linkage Protocol - ✔✔Appropriateness of Codes, Payers rules about
linkage, Documentation to support codes, Compliance with regulation and guidelines
✔✔Life Cycle of a Claim - ✔✔Submission, Processing, Adjudication, Non-covered,
Unauthorized, Medical Necessity Checks, Payment / RA / ERA
✔✔What does MAC stand for? - ✔✔Medicare Administrative Contractor
✔✔"A condition that develops after, the outpatient care has been provided or during an
inpatient admission." - ✔✔Complication
✔✔"A concurrent condition that coexists with the first-listed diagnosis or principal
diagnosis, has potential to affect treatment of the aforementioned diagnosis and is an
active condition for which the patient is treated and/or monitored." - ✔✔Comorbidity
✔✔The process by which the provider contacts the insurance carrier to see if the
proposed procedure is covered by a specific patients insurance policy. -
✔✔Preauthorization
✔✔Monies or Funds that are owed to the practice for services provided - ✔✔Accounts
Receivable (A/R)
✔✔Monies being paid from the medical practice, for instance to pay for supplies, rent,
utilities, payroll, etc. - ✔✔Accounts Payable (A/P)
