CBCS - CPC Exam - Claims Processing and Compliance || A+
Certified.
Adjudication is the process health plans follow to _____ claims and determine ____ . correct
answers examine; payment. The payer's computer systems applies edits that reflect their payment
policies through a process called automated review.
Audit - a review or formal examination of a _____ _______or a ____ ____ records. correct
answers provider's accounting; patient's medical
Carrier block is the data entry area located in the _____ ____ corner of the CMS-1500 that
allows for a ____-____ address for the ______. correct answers upper right; four-line; payer
Clearinghouse ____ and ____ electronic _____ to the _____ carrier for payment. correct answers
edits and routes; claims; insurance
CMS 1500 used to submit ____ claims for _____ and _____ rendered by ______ and other
health care professionals on an _____ basis. correct answers paper; services and procedures;
physicians; outpatient
continuity of care is coordinating _____ and ____ _____ between patients' _____ _____
providers. correct answers treatment and health services; health care
Health plans, health care clearinghouses, or health care providers that conduct health information
in electronic form in connection with a transaction covered by HIPAA are _____ ____. correct
answers covered entities
A Claim status indicating a claim has been processed, but contained incorrect or incomplete
information; a claim may also be denied for medical necessity is a ___ ___ ___. correct answers
denied claim status
, Durable medical equipment (DME) according to CMS is "... equipment that can withstand _____
use; is primarily and customarily used to serve a ____ purpose; generally is not useful to a
person in absence of ___ or ____; and is appropriate for use in the ____. DME is also referred as
DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies). correct answers
repeated; medical; injury or illness; home;
Electronic data interchange (EDI) is a secure ____-to-_____ interchange of _____ in a _____
format. correct answers system-to-system; data; standardized
Eligibility verification is the confirmation that the _____ is entitled to benefits by verifying the
____ of the insurance carrier, the effective _____ of active coverage, policy information, group
____, copayments, and deductible; typically performed ______ services are _______. correct
answers patient; name; date; number; before; rendered
Employer identification number (EIN) is the unique ______ issued by the ___ ____ ____ (IRS)
for employers as required by HIPAA ____ ___ ____ Transactions and ___ sets when submitting
claims. correct answers identifier; Internal Revenue Service; Electronic Health Care; Code
First party is the correct answers insured
Guarantor is the party _____ for _____ of services provided. correct answers responsible;
payments
HIPAA Electronic Health Care Transactions and Codes Sets are HIPAA ______ of electronic
____ of health care ____, including data _____, standard ___ sets, _____ health identifiers,
_____ safeguards, and _____ standards. correct answers standardization; transactions; data;
elements; code; unique; security; privacy
HIPAA National Identifiers are required ______ systems for health care ______ and health care
_____. correct answers identification; providers; organizations
Certified.
Adjudication is the process health plans follow to _____ claims and determine ____ . correct
answers examine; payment. The payer's computer systems applies edits that reflect their payment
policies through a process called automated review.
Audit - a review or formal examination of a _____ _______or a ____ ____ records. correct
answers provider's accounting; patient's medical
Carrier block is the data entry area located in the _____ ____ corner of the CMS-1500 that
allows for a ____-____ address for the ______. correct answers upper right; four-line; payer
Clearinghouse ____ and ____ electronic _____ to the _____ carrier for payment. correct answers
edits and routes; claims; insurance
CMS 1500 used to submit ____ claims for _____ and _____ rendered by ______ and other
health care professionals on an _____ basis. correct answers paper; services and procedures;
physicians; outpatient
continuity of care is coordinating _____ and ____ _____ between patients' _____ _____
providers. correct answers treatment and health services; health care
Health plans, health care clearinghouses, or health care providers that conduct health information
in electronic form in connection with a transaction covered by HIPAA are _____ ____. correct
answers covered entities
A Claim status indicating a claim has been processed, but contained incorrect or incomplete
information; a claim may also be denied for medical necessity is a ___ ___ ___. correct answers
denied claim status
, Durable medical equipment (DME) according to CMS is "... equipment that can withstand _____
use; is primarily and customarily used to serve a ____ purpose; generally is not useful to a
person in absence of ___ or ____; and is appropriate for use in the ____. DME is also referred as
DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies). correct answers
repeated; medical; injury or illness; home;
Electronic data interchange (EDI) is a secure ____-to-_____ interchange of _____ in a _____
format. correct answers system-to-system; data; standardized
Eligibility verification is the confirmation that the _____ is entitled to benefits by verifying the
____ of the insurance carrier, the effective _____ of active coverage, policy information, group
____, copayments, and deductible; typically performed ______ services are _______. correct
answers patient; name; date; number; before; rendered
Employer identification number (EIN) is the unique ______ issued by the ___ ____ ____ (IRS)
for employers as required by HIPAA ____ ___ ____ Transactions and ___ sets when submitting
claims. correct answers identifier; Internal Revenue Service; Electronic Health Care; Code
First party is the correct answers insured
Guarantor is the party _____ for _____ of services provided. correct answers responsible;
payments
HIPAA Electronic Health Care Transactions and Codes Sets are HIPAA ______ of electronic
____ of health care ____, including data _____, standard ___ sets, _____ health identifiers,
_____ safeguards, and _____ standards. correct answers standardization; transactions; data;
elements; code; unique; security; privacy
HIPAA National Identifiers are required ______ systems for health care ______ and health care
_____. correct answers identification; providers; organizations
