WEEK 11 MEDICAL BILLING &
REIMBURSEMENT ESSENTIALS
QUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
Which is the term for the person that is responsible for a bill in the medical office? - ANSWER Guarantor
Rationale
The guarantor is a term for the person who is responsible for the bill. This person is not necessarily a
patient. Grandfathered refers to a provision in which an old rule continues to apply to some existing
situations while a new rule will apply to all future cases. Grandfathered is an exception to a rule, most
likely a new rule that applies to a current situation by a particular deadline. Member is a term for the
person who subscribes to the insurance plan.
Text reference: p. 392
The medical biller expects to inquire about the status of a claim after which number of days if no
response has been received from the insurance company? - ANSWER 30
Rationale
If no response has been received from the insurance company after 30 days, the medical biller should
inquire about the status of the claim. Within 14 and 21 days is too soon to inquire about the status of
the claim, and 45 days is much longer than needed to wait to inquire about the status of the claim.
Text reference: p. 390
What is the process by which an insurance company allows a provider to electronically submit claims
directly to the company? - ANSWER Direct billing
Rationale
Direct billing is the process by which an insurance company allows a health provider to electronically
submit claims directly to the insurance company. Express invoicing, automated billing, and automatic
,submission are not the correct methods that allow a health provider to electronically submit claims
directly to the insurance company.
Text reference: p. 380
The medical assistant ensures that which document, signed by the patient, is kept in the person's health
record and allows the release of medical data to the insurance company? - ANSWER Release of
information
Rationale
A medical release of information form, signed by the patient, is kept in the person's health record and
allows the release of patient health and medical information to the insurance company. The assignment
of benefits is the patient's statement regarding whether the payment of all insurance benefits for
medical services rendered are to be directly to the form is the document that the patient signs prior to
services being rendered. It states that a person wants to be treated for an underlying health condition
and that the medical care provider can perform the treatment. The health directive form is signed by the
patient to state the type of treatment or the declination of treatment that the patient wants carried out
in the event that the patient is unable to state his or her wishes at the time of treatment.
Text reference: p. 378
What is an unintended action that directly or indirectly results in an overpayment to the healthcare
provider? - ANSWER Abuse
Rationale
Abuse is an unintended action that directly or indirectly results in an overpayment to the healthcare
provider. Fraud is defined as knowingly and willfully executing or attempting to execute a scheme to
defraud any healthcare benefit program or to obtain by means of false or fraudulent pretenses,
representations, or promises of any of the money or property owned by any healthcare benefit program.
Negligence is the failure to exercise reasonable care in one's actions by taking account of the potential
harm that might be caused to other people or property. Exploitation is the act of making use of a
situation to gain unfair advantage for oneself.
Text reference: p. 385
, Which action starts the medical billing process? - ANSWER When the patient makes an appointment
Rationale
The medical billing process starts when a patient makes an appointment. The billing process is complete
when payment has been received. The patient arriving for the appointment and paying the copayment
do not start the billing process.
Text reference: p. 377
Electronic claims are insurance claims that are transmitted over the Internet from the provider to the
health insurance company through which process? - ANSWER Electronic data interchange
Rationale
Electronic claims are insurance claims that are transmitted over the Internet from the provider to the
health insurance company through electronic data interchange. Internet file transfer, automated claims
network, and automatic claims transmission each partially describe the process but are not the correct
name of the process.
Text reference: p. 380
The medical assistant can expect a denial of which type of claims with incorrect, missing, or insufficient
data? - ANSWER Dirty Claims
Rationale
Claims with incorrect, missing, or insufficient data are called dirty claims. False claims, flawed claims, and
erroneous claims are not the correct terms for claims with incorrect, missing, or insufficient data.
Text reference: p. 389
What child health program under Medicaid is addressed in Block 24H of the CMS-1500 Health Insurance
Claim Form where specific services covered under state health insurance plans are identified? - ANSWER
Early and Periodic Screening, Diagnosis, and Treatment
REIMBURSEMENT ESSENTIALS
QUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
Which is the term for the person that is responsible for a bill in the medical office? - ANSWER Guarantor
Rationale
The guarantor is a term for the person who is responsible for the bill. This person is not necessarily a
patient. Grandfathered refers to a provision in which an old rule continues to apply to some existing
situations while a new rule will apply to all future cases. Grandfathered is an exception to a rule, most
likely a new rule that applies to a current situation by a particular deadline. Member is a term for the
person who subscribes to the insurance plan.
Text reference: p. 392
The medical biller expects to inquire about the status of a claim after which number of days if no
response has been received from the insurance company? - ANSWER 30
Rationale
If no response has been received from the insurance company after 30 days, the medical biller should
inquire about the status of the claim. Within 14 and 21 days is too soon to inquire about the status of
the claim, and 45 days is much longer than needed to wait to inquire about the status of the claim.
Text reference: p. 390
What is the process by which an insurance company allows a provider to electronically submit claims
directly to the company? - ANSWER Direct billing
Rationale
Direct billing is the process by which an insurance company allows a health provider to electronically
submit claims directly to the insurance company. Express invoicing, automated billing, and automatic
,submission are not the correct methods that allow a health provider to electronically submit claims
directly to the insurance company.
Text reference: p. 380
The medical assistant ensures that which document, signed by the patient, is kept in the person's health
record and allows the release of medical data to the insurance company? - ANSWER Release of
information
Rationale
A medical release of information form, signed by the patient, is kept in the person's health record and
allows the release of patient health and medical information to the insurance company. The assignment
of benefits is the patient's statement regarding whether the payment of all insurance benefits for
medical services rendered are to be directly to the form is the document that the patient signs prior to
services being rendered. It states that a person wants to be treated for an underlying health condition
and that the medical care provider can perform the treatment. The health directive form is signed by the
patient to state the type of treatment or the declination of treatment that the patient wants carried out
in the event that the patient is unable to state his or her wishes at the time of treatment.
Text reference: p. 378
What is an unintended action that directly or indirectly results in an overpayment to the healthcare
provider? - ANSWER Abuse
Rationale
Abuse is an unintended action that directly or indirectly results in an overpayment to the healthcare
provider. Fraud is defined as knowingly and willfully executing or attempting to execute a scheme to
defraud any healthcare benefit program or to obtain by means of false or fraudulent pretenses,
representations, or promises of any of the money or property owned by any healthcare benefit program.
Negligence is the failure to exercise reasonable care in one's actions by taking account of the potential
harm that might be caused to other people or property. Exploitation is the act of making use of a
situation to gain unfair advantage for oneself.
Text reference: p. 385
, Which action starts the medical billing process? - ANSWER When the patient makes an appointment
Rationale
The medical billing process starts when a patient makes an appointment. The billing process is complete
when payment has been received. The patient arriving for the appointment and paying the copayment
do not start the billing process.
Text reference: p. 377
Electronic claims are insurance claims that are transmitted over the Internet from the provider to the
health insurance company through which process? - ANSWER Electronic data interchange
Rationale
Electronic claims are insurance claims that are transmitted over the Internet from the provider to the
health insurance company through electronic data interchange. Internet file transfer, automated claims
network, and automatic claims transmission each partially describe the process but are not the correct
name of the process.
Text reference: p. 380
The medical assistant can expect a denial of which type of claims with incorrect, missing, or insufficient
data? - ANSWER Dirty Claims
Rationale
Claims with incorrect, missing, or insufficient data are called dirty claims. False claims, flawed claims, and
erroneous claims are not the correct terms for claims with incorrect, missing, or insufficient data.
Text reference: p. 389
What child health program under Medicaid is addressed in Block 24H of the CMS-1500 Health Insurance
Claim Form where specific services covered under state health insurance plans are identified? - ANSWER
Early and Periodic Screening, Diagnosis, and Treatment
