MNT II: Billing and Coding Exam Practice Questions and Answers

MNT II: Billing and Coding Exam Practice Questions and Answers Health care provider or supplier agrees (or is required by law to accept the third party payer-approved amount as full payment for covered services and not to bill the client for any more than the deductible and coinsurance. - Ans:-Accept Assignment A group of care providers who give coordinate care and chronic disease management, and thereby improve the quality of care patients get. The organization's payment is tied to achieving health care quality goals and outcomes that result in cost saving. - Ans:-Accountable Care Organization The amount of money charged by the health care provider or supplier for a certain medical service or supply. This amount is often more than the amount Medicare or third party payers approve. - Ans:- Actual charge May also be known as a waiver of liability. A notice health care providers and suppliers are required to give and have signed by Original Medicare when they believe that Medicare will not cover the services or items and the person has no reason to know that Medicare will not cover these services or items. If no ABN is not provided by provider, the Medicare insured does not have to pay but if he/she signed an ABN ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/16 for the service/item then they are responsible and Medicare does not have to pay. - Ans:-Advance Beneficiary Notice (ABN) Generic term referring to the maximum fee that a third party will use to reimburse a provider for a given service. - Ans:-Allowable charge A request by a beneficiary or a provider to have a review when health care services are denied based on medical necessity or appropriateness, or improperly paid. - Ans:-Appeal A referral that has been submitted to the patient's insurance company for approval for the services requested to be performed. - Ans:-Authorization Balance billing is the practice of billing a patient for charges not paid by his/her insurance plan because the charges are in excess of covered amounts. Balance billing amount will often be charges that are beyond the fee schedule or contract rate. - Ans:-Balance Bill A person who is covered by the third party payer - Ans:-Beneficiary The specified period of time during which charges for covered services must be incurred in order to be eligible for payment by a third party payer. - Ans:-Benefit period The reimbursement of health care providers (such as hospitals and physicians) on the basis of expected costs for clinically-defined episodes of care. It has been described as a "middle ground" between fee for service reimbursement (in which providers are paid for each service rendered to a patient) and ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/16 capitation (in which providers are paid a "lump sum" per patient regardless of how many services the patient receives). Bundled payments have been proposed in the health care reform debate in the United States as a strategy for reducing health care costs. - Ans:-Bundled Payment A payment arrangement for health care service providers based on a set amount for enrolled persons assigned to them rather than a payment per service provided. The provider is paid whether or not the enrolled person seeks care. - Ans:-Capitation A payment system that measures the intensity of care and services required for each patient, and translates these measures into the amount of reimbursement given to the facility for care of a patient. Payment if linked to the intensity of resource use. - Ans:-Case Mix Reimbursement System An electronic list of a facility's services and supplies, billing codes and the associated charges. The charge master must be kept updated to the latest codes and government billing regulations for health claims. - Ans:-Charge Master A request for payment for the service(s) provided by a health care provider. - Ans:-Claim The 1500 claim form is the universal insurance claim form developed and approved by the AMA and Centers for Medicare and Medicaid Services. This form is used by non-institutional providers/suppliers to bill Medicare carriers, commercial/private insurance and billing of some Medicaid State Agencies. - Ans:-1500 Claim Form ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 4/16 A federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards. - Ans:-CMS Provides health coverage to nearly 8 million children in families with incomes too high to qualify for Medicaid, but who can't afford private coverage. Signed into law in 1997, CHIP provides federal matching funds to state to provide this coverage. - Ans:-Children's Health Insurance Program (CHIP) The sharing of costs by two or more health plans, based on their respective financial responsibilities for medical claims. A primary insurance and secondary insurance must coordinate benefits in order to pay claims. If one of the plans is Medicare, federal law may decide who pays first. - Ans:-Coordination of Benefits (COB) A set amount determined by the third party payer that the in