Medical Insurance 7e Chapter 13

A __________occurs when a procedure and a diagnosis are not correctly linked, in the opinion of the payer.

• determination

• development

• medical necessity denial

• redetermination

A payer may _________ a procedure that it determines was not medically necessary at the level reported.

• bundle

• concurrent code

• downcode

• upcode

_____________ is the process of determining whether to pay, reject, deny, or partially pay claims.

• adjudication

• appearing

• determination

• redetermination

What is the correct order for the basic steps of a payer's adjudication process?

• automated review, initial processing, manual review, determination, and payment.

• initial processing, automated review, manual review, determination, and payment

• initial processing, manual review, automated review determination, and payment.

• manual review initial processing, automated review, determination, and payment.

The term ______________ during claim adjudication means that the payer needs more information to process the claim.

• determination

• development

• suspended

• redetermination

Minor errors found by the practice on transmitted claims require which of the following

• a completely new claim to be filed

• corrections by asking the payer to reopen the claim and make the changes

• corrections by asking the payer to adjust the charges

• a denial

What will a payer do when a claim is submitted with outdated procedure codes?

• payers are not permitted to deny a claim when outdated procedure codes are used

• payers will not respond to the claim

• payers may deny a claim when outdated procedure codes are used

• payers will typically pay and submit the claim to the provider with the correct procedure codes

Concurrent care is care provided:

• at the same place of service by two or more physicians

• at the same place as a previous visit

• by two physician practices on the same date by two physicians

• to a patient on the same date at the same place of service by two or more physicians

Which of the following is an example of concurrent care?

• a case in which a patient is attended by two physicians, such as a cardiologist and a thoracic surgeon, during surgery

• a case in which a patient is seen in the emergency room and transferred across town to a different facility

• a case in which a patient is seen in the emergency room and then admitted by a different doctor to the floor

• a case in which a nurse practitioner sees the patient and then transfers the care to a physician

The claim turnaround time is the period between

• the patient's encounter and the transmission of the resulting claim

• the patient's encounter and the date it was billed to the insurance

• the date the claim was paid by insurance to the time the patient paid his/her portion.

• the date of claim transmission and receipt of payment