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week 4
chapter 16-17
| Question | Answer |
|---|---|
| What is an Explanation of Benefits | Notification sent by insurance carrier to the patient and provider after a claim has been processed. |
| Define adjudication | Steps that result in an insurance carrier's decision to either pay or deny a claim |
| How should you appeal for reconsideration of a carrier's decision | in writing |
| What does the State Insurance Commissioner do | state official who has regulatory control over insurance carriers and can assist with disputes |
| Who is the Explanantion of Benefits sent to | provider and patient |
| What are the two main methods used by providers to determine their fees | charge-based and resource-based fee structures |
| Who updates the Medical Conversion factor annually | The Center for Medicare and Medicaid CMS |
| Define Nonparticipating provider | A nonparticipating provider who is able to balance-bill for the amount over carrier's allowed charges |
| Define withhold | Percentage of the provider's payment that is not paid during a contract year but is kept by the health plan to offset additional costs including for references, hospital admission, or other covered services |
| Under most insurance plans when does the deductible apply to each covered individual | calendar year |
| What is peer review | An objective, unbiased group of physicians that determines what payment for services |
| Who may ask the state insurance commissioner to help in resolving a payment dispute | patients, physician, insurance carriers |
| Define documentation | The chronological recording of pertinent facts and observations regarding a patient's health status |
| What does SOAP stand for | Subjective, Objective, Assessment, and Plan |
| Where can the medical office specialist learn about insurance carrier's appeal process | Administrative manual or newsletters from the carriers, or call the carrier |
| What is the low that protects the interest of beneficiaries enrolled on private employee benefit plans | ERISA |
| How long does a qualified independent contractor have to process a reconsideration | 60 days |
| How long does Medicare have to process a redetermination | 30 days |
| To take a Medicare appeal to the level of decision by an administrative law judge, the claim must be a minimum of what amount | $130 |
| Define disallowance | A provider receives a partial payment on a claim because the amount billed was in excess of the maximum allowed charges. |
Created by:
vpolosukhina
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