NHA CBCS Study Guide Questions With
Correct Answers
Adjudication
The process where the insurance company receives a claim and makes a
| | | | | | | | | | | |
determination on payment or denial. | | | |
Allowed Amount |
The maximum amount an insurance company will pay for the service,
| | | | | | | | | | |
procedure, or supply. | |
Auditing Process |
The act of reviewing and comparing the patient medical records and
| | | | | | | | | | |
claims to assess for coding appropriateness and completeness of the
| | | | | | | | | |
medical documentation.
|
Coding Compliance
|
,The conformity and adherence to established coding guidelines and
| | | | | | | | |
regulations.
Current Procedural Terminology (CPT)
| | |
Descriptive definitions used to explain procedures and services provided
| | | | | | | | |
to the patient.
| |
Denied Claim |
A claim returned from a third-party payer because of technical errors or
| | | | | | | | | | | |
patient coverage errors.
| |
Explanation of Benefits (EOB) | | |
Document that explains how the payer processed the claim for services
| | | | | | | | | | |
rendered; can also be referred to as remittance advice (RA).
| | | | | | | | |
Fee-for-Service
Cost or fee that is charged for each individual service.
| | | | | | | | |
,Health and Human Services
| | |
Government department that oversees the health of the community and
| | | | | | | | | |
provides crucial services. | |
International Classification of Diseases, Tenth revision, Clinical
| | | | | | |
Modification (ICD-10-CM) |
List of codes used to report and classify diseases, conditions and other
| | | | | | | | | | | |
reasons for health care encounters.
| | | |
Noncompliance
The act of disregarding rules and guidelines outlined by state and federal
| | | | | | | | | | | |
government agencies and third-party payers.
| | | |
Office of Inspector General (OIG)
| | | |
Government department that investigates fraud and abuse.
| | | | | |
Place of Service (POS) Code
| | | |
, Two-digit code that identifies where the services were performed.
| | | | | | | |
Abuse
Billing patterns and practices that are excessive or unnecessary but not
| | | | | | | | | | |
fraudulent. - When the provider unknowingly or unintentionally
| | | | | | | |
misrepresented information on a claim for reimbursement.
| | | | | |
Accounts Receivable |
The amount owed to a provider for health care services rendered.
| | | | | | | | | |
Appeals Process |
A process used to request review of a claim that was denied---to
| | | | | | | | | | | |
determine if the denial was due to a billing error; if so, correct it; file an
| | | | | | | | | | | | | | | |
appeal at the lowest level; and then move up to higher levels if needed.
| | | | | | | | | | | | |
Assignment of Benefits | |
Method of a patient requesting their claim benefits be paid to the health
| | | | | | | | | | | | |
care organization that provided the service.
| | | | |
Correct Answers
Adjudication
The process where the insurance company receives a claim and makes a
| | | | | | | | | | | |
determination on payment or denial. | | | |
Allowed Amount |
The maximum amount an insurance company will pay for the service,
| | | | | | | | | | |
procedure, or supply. | |
Auditing Process |
The act of reviewing and comparing the patient medical records and
| | | | | | | | | | |
claims to assess for coding appropriateness and completeness of the
| | | | | | | | | |
medical documentation.
|
Coding Compliance
|
,The conformity and adherence to established coding guidelines and
| | | | | | | | |
regulations.
Current Procedural Terminology (CPT)
| | |
Descriptive definitions used to explain procedures and services provided
| | | | | | | | |
to the patient.
| |
Denied Claim |
A claim returned from a third-party payer because of technical errors or
| | | | | | | | | | | |
patient coverage errors.
| |
Explanation of Benefits (EOB) | | |
Document that explains how the payer processed the claim for services
| | | | | | | | | | |
rendered; can also be referred to as remittance advice (RA).
| | | | | | | | |
Fee-for-Service
Cost or fee that is charged for each individual service.
| | | | | | | | |
,Health and Human Services
| | |
Government department that oversees the health of the community and
| | | | | | | | | |
provides crucial services. | |
International Classification of Diseases, Tenth revision, Clinical
| | | | | | |
Modification (ICD-10-CM) |
List of codes used to report and classify diseases, conditions and other
| | | | | | | | | | | |
reasons for health care encounters.
| | | |
Noncompliance
The act of disregarding rules and guidelines outlined by state and federal
| | | | | | | | | | | |
government agencies and third-party payers.
| | | |
Office of Inspector General (OIG)
| | | |
Government department that investigates fraud and abuse.
| | | | | |
Place of Service (POS) Code
| | | |
, Two-digit code that identifies where the services were performed.
| | | | | | | |
Abuse
Billing patterns and practices that are excessive or unnecessary but not
| | | | | | | | | | |
fraudulent. - When the provider unknowingly or unintentionally
| | | | | | | |
misrepresented information on a claim for reimbursement.
| | | | | |
Accounts Receivable |
The amount owed to a provider for health care services rendered.
| | | | | | | | | |
Appeals Process |
A process used to request review of a claim that was denied---to
| | | | | | | | | | | |
determine if the denial was due to a billing error; if so, correct it; file an
| | | | | | | | | | | | | | | |
appeal at the lowest level; and then move up to higher levels if needed.
| | | | | | | | | | | | |
Assignment of Benefits | |
Method of a patient requesting their claim benefits be paid to the health
| | | | | | | | | | | | |
care organization that provided the service.
| | | | |
