CBCS exam Review QUESTIONS AND VERIFIED ANSWERS 2025(GRADED A+)
DETAILED ANSWERS!!
2 categories of denied claims - ✔✔technical errors or patient coverage errors
4 Review by the medicare appeals counsel(appeal process) - ✔✔Filed w council
in writing - must be filed w/in 60 calendar days of the OMHA decision
5 Judicial review in US District court(appeal process) - ✔✔Filed in a district court
according to the details provided by the counsel's response. must be w/in 60
days of t he counsel's decision
ABN (Advance Beneficiary Notice) - ✔✔mechanism used to mitigate denied
claim due to lack of medical necessity. Documents beneficiary's decision about
uncovered service. Service must be reviewed with patient before signing. Form
serves as informed consent to transfer responsibility to patient if medicare does
not pay for service. Patient can decline. Signing just reassigns liability for service
abuse - ✔✔billing patterns and practices that are excessive or unnecessary but
not fraudulent
adjudication - ✔✔clean claims submitted to payers are processed and paid
according to the individual plan, determining financial responsibility among the
stakeholders
aging report - ✔✔a report that shows the length of outstanding balances in the
system
,appeal - ✔✔the official process of requesting a review of a claim that was
underpayed or denied
Assignment of benefits - ✔✔method of patient requesting their claim benefits
to be paid to the healthcare organization that provided services
Auto Insurance - ✔✔covers driver and/or passengers in vehicle accidents
Batch claim report - ✔✔summarizes claimi details including patient, payer, and
date of transmission
beneficiary - ✔✔person eligible to receive benefits for covered healthcare
services rendered
capitation - ✔✔an agreement w a provider to receive a pre-established
payment for health care services to enrollees, over a period of time
claims editing - ✔✔a step in the claims process in which appropriate codes and
rules are verified before the claim is submitted
clean claims process - ✔✔1. billing and coding specialist completes a CMS-1500
claim or 837 P claim 2. Billing and coding specialist batches claims and submits
to clearing house 3. clearinghouse scans CMS-1500 and converts to electronic
flat file format / clearinghouse converts 837P into electronic flat file format 4.
clearinghouse verifies claims data and transmits to payers
, clinical documentation - ✔✔information recorded in medical record pertaining
to the health status of a patient as determined by a healthcare provider
coinsurance - ✔✔predetermined percentage the patient is responsible to pay
for covered services once the annual deductible has been met
compliance plans - ✔✔included in policies and procedures manual, is specific to
type and size of organization, addresses compliance rules and regulations of
government and private payers. Created culture that manages and protects the
administration of healcare service to patients
confidentiality and security - ✔✔confidentiality: protection of patient info from
any unauthorized persons
security: protection of patient info
consultation report - ✔✔includes physical exam and test results, along with the
consultant's expert opinion about the patient's conditionf
coordination of benefits - ✔✔provision of health care plans to define the order
of responsibility for claims when there is more than one payer. Prevents
duplicate payments, underpayments, or overpayments
copayment (copay) - ✔✔flat, fixed amount patient pays for specific services
coverage errors include: - ✔✔-service not covered by health insurance
-Patient not covered by policy at time of service
-service not considered medically necessary
DETAILED ANSWERS!!
2 categories of denied claims - ✔✔technical errors or patient coverage errors
4 Review by the medicare appeals counsel(appeal process) - ✔✔Filed w council
in writing - must be filed w/in 60 calendar days of the OMHA decision
5 Judicial review in US District court(appeal process) - ✔✔Filed in a district court
according to the details provided by the counsel's response. must be w/in 60
days of t he counsel's decision
ABN (Advance Beneficiary Notice) - ✔✔mechanism used to mitigate denied
claim due to lack of medical necessity. Documents beneficiary's decision about
uncovered service. Service must be reviewed with patient before signing. Form
serves as informed consent to transfer responsibility to patient if medicare does
not pay for service. Patient can decline. Signing just reassigns liability for service
abuse - ✔✔billing patterns and practices that are excessive or unnecessary but
not fraudulent
adjudication - ✔✔clean claims submitted to payers are processed and paid
according to the individual plan, determining financial responsibility among the
stakeholders
aging report - ✔✔a report that shows the length of outstanding balances in the
system
,appeal - ✔✔the official process of requesting a review of a claim that was
underpayed or denied
Assignment of benefits - ✔✔method of patient requesting their claim benefits
to be paid to the healthcare organization that provided services
Auto Insurance - ✔✔covers driver and/or passengers in vehicle accidents
Batch claim report - ✔✔summarizes claimi details including patient, payer, and
date of transmission
beneficiary - ✔✔person eligible to receive benefits for covered healthcare
services rendered
capitation - ✔✔an agreement w a provider to receive a pre-established
payment for health care services to enrollees, over a period of time
claims editing - ✔✔a step in the claims process in which appropriate codes and
rules are verified before the claim is submitted
clean claims process - ✔✔1. billing and coding specialist completes a CMS-1500
claim or 837 P claim 2. Billing and coding specialist batches claims and submits
to clearing house 3. clearinghouse scans CMS-1500 and converts to electronic
flat file format / clearinghouse converts 837P into electronic flat file format 4.
clearinghouse verifies claims data and transmits to payers
, clinical documentation - ✔✔information recorded in medical record pertaining
to the health status of a patient as determined by a healthcare provider
coinsurance - ✔✔predetermined percentage the patient is responsible to pay
for covered services once the annual deductible has been met
compliance plans - ✔✔included in policies and procedures manual, is specific to
type and size of organization, addresses compliance rules and regulations of
government and private payers. Created culture that manages and protects the
administration of healcare service to patients
confidentiality and security - ✔✔confidentiality: protection of patient info from
any unauthorized persons
security: protection of patient info
consultation report - ✔✔includes physical exam and test results, along with the
consultant's expert opinion about the patient's conditionf
coordination of benefits - ✔✔provision of health care plans to define the order
of responsibility for claims when there is more than one payer. Prevents
duplicate payments, underpayments, or overpayments
copayment (copay) - ✔✔flat, fixed amount patient pays for specific services
coverage errors include: - ✔✔-service not covered by health insurance
-Patient not covered by policy at time of service
-service not considered medically necessary
