ES
ID
U
EG
R
O
SC
, ES
ID
U
EG
R
O
SC
, ES
ID
U
EG
R
O
SC
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
6. If a health insurance plan’s prior approval requirements are not met by providers and
the claim is submitted for reimbursement,
a. administrative costs are reduced.
b. patients’ coverage is cancelled.
c. payment of the claim is denied.
d. they pay a fine to the health plan.
ANS: c
Analysis:
a. Incorrect. Administrative cost actually increase as a result of billing the patient
for services provided, submitting the bill to collections, and writing off the billed
amount. If a health insurance plan’s prior approval requirements are not met by
providers and the claim is submitted for reimbursement, the third-party payer
SC
issues claims denials.
b. Incorrect. The patient’s coverage is not cancelled when prior approval requirements
are not met. If a health insurance plan’s prior approval requirements are not met by
providers and the claim is submitted for reimbursement, the patient’s coverage will
not be cancelled or impacted but the payer will deny the claim.
c. Correct. If a health insurance plan’s prior approval requirements are not met by
providers and the claim is submitted for reimbursement, the third-party payer
O
issues claims denials.
d. Incorrect. Providers and patients do not pay a fine to the health plan when prior
approval requirements are not met. If a health insurance plan’s prior approval
requirements are not met by providers and the claim is submitted for
R
reimbursement, the third-party payer issues claims denials.
7. Which coding system is used to report diagnoses and conditions on claims?
a. CPT
b. HCPCS Level II
EG
c. ICD-10-CM
d. ICD-10-PCS
ANS: c
Analysis:
a. Incorrect. CPT, or Current Procedural Terminology, is used to report procedures or
services on outpatient and physician office claims. ICD-10-CM, or International
U
Classification of Diseases, 10th Revision, Clinical Modification, is used to report
diagnoses and conditions on all claims.
b. Incorrect. HCPCS Level II, or Healthcare Common Procedure Coding System Level II,
codes are used to report procedures or services on outpatient and physician office
ID
claims, especially for medical devices and supplies. ICD-10-CM, or International
Classification of Diseases, 10th Revision, Clinical Modification, is used to report
diagnoses and conditions on all claims.
c. Correct. ICD-10-CM, or International Classification of Diseases, 10th Revision,
Clinical Modification, is used to report diagnoses and conditions on all claims.
ES
d. Incorrect. ICD-10-PCS, or International Classification of Diseases, 10th Revision,
Procedure Coding System, is used to report inpatient hospital procedures or
services on UB-04 claims. ICD-10-CM, or International Classification of Diseases,
10th Revision, Clinical Modification, is used to report diagnoses and conditions
on all claims.
ID
U
EG
R
O
SC
, ES
ID
U
EG
R
O
SC
, ES
ID
U
EG
R
O
SC
, Solution and Answer Guide: Michelle A. Green, Understanding Health Insurance: A Guide to Billing and
Reimbursement: 2024, 19th Edition, 9780357932063; Chapter 1: Health Insurance Specialist Career
6. If a health insurance plan’s prior approval requirements are not met by providers and
the claim is submitted for reimbursement,
a. administrative costs are reduced.
b. patients’ coverage is cancelled.
c. payment of the claim is denied.
d. they pay a fine to the health plan.
ANS: c
Analysis:
a. Incorrect. Administrative cost actually increase as a result of billing the patient
for services provided, submitting the bill to collections, and writing off the billed
amount. If a health insurance plan’s prior approval requirements are not met by
providers and the claim is submitted for reimbursement, the third-party payer
SC
issues claims denials.
b. Incorrect. The patient’s coverage is not cancelled when prior approval requirements
are not met. If a health insurance plan’s prior approval requirements are not met by
providers and the claim is submitted for reimbursement, the patient’s coverage will
not be cancelled or impacted but the payer will deny the claim.
c. Correct. If a health insurance plan’s prior approval requirements are not met by
providers and the claim is submitted for reimbursement, the third-party payer
O
issues claims denials.
d. Incorrect. Providers and patients do not pay a fine to the health plan when prior
approval requirements are not met. If a health insurance plan’s prior approval
requirements are not met by providers and the claim is submitted for
R
reimbursement, the third-party payer issues claims denials.
7. Which coding system is used to report diagnoses and conditions on claims?
a. CPT
b. HCPCS Level II
EG
c. ICD-10-CM
d. ICD-10-PCS
ANS: c
Analysis:
a. Incorrect. CPT, or Current Procedural Terminology, is used to report procedures or
services on outpatient and physician office claims. ICD-10-CM, or International
U
Classification of Diseases, 10th Revision, Clinical Modification, is used to report
diagnoses and conditions on all claims.
b. Incorrect. HCPCS Level II, or Healthcare Common Procedure Coding System Level II,
codes are used to report procedures or services on outpatient and physician office
ID
claims, especially for medical devices and supplies. ICD-10-CM, or International
Classification of Diseases, 10th Revision, Clinical Modification, is used to report
diagnoses and conditions on all claims.
c. Correct. ICD-10-CM, or International Classification of Diseases, 10th Revision,
Clinical Modification, is used to report diagnoses and conditions on all claims.
ES
d. Incorrect. ICD-10-PCS, or International Classification of Diseases, 10th Revision,
Procedure Coding System, is used to report inpatient hospital procedures or
services on UB-04 claims. ICD-10-CM, or International Classification of Diseases,
10th Revision, Clinical Modification, is used to report diagnoses and conditions
on all claims.
