NHA Domain 4 Review

Front

Which of the following information is needed to accurately review, evaluate, and resolve denied claims?
- An aging report breakdown of a patient’s account
- A remittance advice with reason codes
- Registration notes
- SOAP notes

Back

A remittance advice with reason codes

Answer explanation

The remittance advice from the third-party payer shows the allowed amount, adjustments, or reason for denial

Front

After a claim is processed by a third-party payer, what action should a billing and coding specialist take to collect the remaining allowed amount? Options: Write off the remaining balance, Submit an adjustment for additional reimbursement, Call the third-party payer to negotiate a higher rate of reimbursement, Prepare and send a patient statement

Back

Prepare and send a patient statement

Answer explanation

As per the contract, providers are obligated to collect all patient financial responsibility from the client as their benefits dictate.

Front

Which of the following unpaid claims listed on a current aging report should a billing and coding specialist review first?
14 days outstanding, 21 days outstanding, 28 days outstanding, 35 days outstanding

Back

35 days outstanding

Answer explanation

This unpaid claim should be reviewed first. The provider needs to file claims with the third-party payer in a timely manner, so the specialist should focus first on unpaid claims that are 31 to 60 days old.

Front

Which of the following is an example of a billing abstraction error? Incorrect date of service used, Authorization was not obtained, Referred services are billed as charges, Secondary insurance was billed as primary insurance

Back

Referred services are billed as charges

Answer explanation

Examples of billing abstraction errors include charging for a service that was referred, not performed.

Front

A billing and coding specialist is reviewing a Medicare Electronic Remittance Advice (RA). The RA indicates that a payment of 80 for a wellness exam. The billed amount was 220 and the allowed amount was 80. What action should the specialist take? Options: Resubmit the claim to be reprocessed for additional payment, Post the payment and write off the difference, Ask the patient to pay the difference, Submit an appeal for the previously processed claim

Back

Post the payment and write off the difference

Answer explanation

Since the payer determined the allowed amount was $80.00 and reimbursed $80.00, the patient financial responsibility is $0.00. The remainder should be written off.

Front

Which resource is used to understand Medicare coverage circumstances such as indications and coding guidance? Options: NCD articles, NCCI edits, Mutually exclusive edits (MUE), Alternative payment model (APM)

Back

NCD articles

Answer explanation

NCD articles explain the coverage circumstances of certain services, including indications and any limitations for the service and coding guidance.

Front

A billing and coding specialist is reviewing a RA that has a remark code indicating a claim is pended for review of the medical records. What should the specialist take? Options: Send the requested records to the third-party payer, Resubmit the claim to the third party payer as a corrected claim, Notify the third party payer to review the claim for payment, Advise the patient that they will be responsible for charges not covered by the payer

Back

Send the requested records to the third-party payer

Answer explanation

The specialist should send the requested medical records to the third-party payer for processing

Front

A billing and coding specialist is reviewing a claims denial for a surgical procedure. After reviewing the original claim, it is determined that services should have been paid. Which scenario eliminates the need for prior authorization? Options: The patient has already been admitted to the hospital, The patient required an emergency procedure, The patient received an elective procedure, The patient is a Medicare beneficiary

Back

The patient required an emergency procedure

Answer explanation

An emergency procedure eliminates the need for prior authorization.

Front

A billing and coding specialist receives a denial from a third party payer due to missing information. Which action should the specialist take to receive reimbursement? Options: Request reimbursement from the patient, Submit an adjustment, Contact the third party payer to provide the information, Resubmit the claim with the completed information

Back

Resubmit the claim with the completed information

Answer explanation

The specialist should resubmit the claim with the completed information.

Front

A patient has Medicare and TRICARE insurance plans. Which of the following should be collected as patient financial responsibility after a procedure? Options: 20% of the total charge of the procedure, 20% of the allowed amount of the procedure, $0, $1000

Back

$0

Answer explanation

The patient is no longer financially responsible for their health care costs because of the dual coverage with Medicare and TRICARE.