Medical Insurance 7e-A Revenue Cycle
Process Approach UPDATED Exam
Questions and CORRECT Answers
billing provider - Correct Answer- provider of health services reported on a claim, usually a
physician practice
clean claim - Correct Answer- claim accepted by a health plan for adjudication
CMS-1500 - Correct Answer- Paper claim for physician services
HIPAA X12 837 Health Care Claim - Correct Answer- electronic form used to send a claim
for physician services to primary & secondary payers
CMS-1500 (02/12) - Correct Answer- current paper claim form approved by NUCC
destination payer - Correct Answer- In HIPAA claims, the health plan receiving the claim.
National Uniform Claim Committee (NUCC) - Correct Answer- Organization responsible for
the content of health care claims.
pay-to provider - Correct Answer- entity that will receive payment for a claim
rendering provider - Correct Answer- healthcare professional who provides health services
reported on a claim
Place of Service (POS) - Correct Answer- administrative code indicating where medical
services were provided
National Provider Identifier (NPI) - Correct Answer- unique ten-digit identifier assigned to
each provider-doctors license number
, subscriber - Correct Answer- The insurance policyholder or guarantor for the claim
the NPI is used to report the ___ on a claim - Correct Answer- provider identifier
list the 5 major actions of the HIPAA claim - Correct Answer- 1.Provider
2.Subscriber
3.Payer info
4.Claim details info
5.Services line info
EMG - Correct Answer- emergency
POS - Correct Answer- place of service
NUCC - Correct Answer- National Uniform Claim Committee
DDE - Correct Answer- Direct Data Entry
carve out - Correct Answer- part of a standard health plan changed under an employer-
sponsored plan
Discounted fee-for-service - Correct Answer- A negotiated payment schedule for health care
services based on a reduced percentage of a provider's usual charges.
elective surgery - Correct Answer- Nonemergency surgical procedure that can be scheduled
in advance.
monthly enrollment list - Correct Answer- Document of eligible members of a capitated plan
registered with a particular PCP for a monthly period.
open enrollment period - Correct Answer- time when a policyholder selects from offered
benefits
Process Approach UPDATED Exam
Questions and CORRECT Answers
billing provider - Correct Answer- provider of health services reported on a claim, usually a
physician practice
clean claim - Correct Answer- claim accepted by a health plan for adjudication
CMS-1500 - Correct Answer- Paper claim for physician services
HIPAA X12 837 Health Care Claim - Correct Answer- electronic form used to send a claim
for physician services to primary & secondary payers
CMS-1500 (02/12) - Correct Answer- current paper claim form approved by NUCC
destination payer - Correct Answer- In HIPAA claims, the health plan receiving the claim.
National Uniform Claim Committee (NUCC) - Correct Answer- Organization responsible for
the content of health care claims.
pay-to provider - Correct Answer- entity that will receive payment for a claim
rendering provider - Correct Answer- healthcare professional who provides health services
reported on a claim
Place of Service (POS) - Correct Answer- administrative code indicating where medical
services were provided
National Provider Identifier (NPI) - Correct Answer- unique ten-digit identifier assigned to
each provider-doctors license number
, subscriber - Correct Answer- The insurance policyholder or guarantor for the claim
the NPI is used to report the ___ on a claim - Correct Answer- provider identifier
list the 5 major actions of the HIPAA claim - Correct Answer- 1.Provider
2.Subscriber
3.Payer info
4.Claim details info
5.Services line info
EMG - Correct Answer- emergency
POS - Correct Answer- place of service
NUCC - Correct Answer- National Uniform Claim Committee
DDE - Correct Answer- Direct Data Entry
carve out - Correct Answer- part of a standard health plan changed under an employer-
sponsored plan
Discounted fee-for-service - Correct Answer- A negotiated payment schedule for health care
services based on a reduced percentage of a provider's usual charges.
elective surgery - Correct Answer- Nonemergency surgical procedure that can be scheduled
in advance.
monthly enrollment list - Correct Answer- Document of eligible members of a capitated plan
registered with a particular PCP for a monthly period.
open enrollment period - Correct Answer- time when a policyholder selects from offered
benefits
