Third Party Payers Practice Test

These questions are part of the practice quiz. Start practicing

• Readmission penalties and how can they affect payer processing?
• HMO reimbursement to providers may be which of the following?
• MACRA ended the sustainable growth rate formula which would adjust payments for physicians and suppliers under Part B. Which act ended the SGR and reformed Medicare payments?
• In payer adjudication, what is the "allowed amount"?
• Which plan type was specifically required to report MLRs under the 2010 ACA provisions?
• In claim adjudication, what is "coordination of benefits" (COB) and why is it important?
• If a person has both an employer-sponsored plan and Medicare at age 65, which payer pays first?
• Part B premiums are deducted from which type of benefits?
• Why is timely denial follow-up important for revenue cycle management?
• Does Medicare Part B have an out-of-pocket maximum?
• What is a value-based care model and its effect on payer payments?
• MACRA stands for?
• What is a 'subrogation' claim and when might it occur?
• States may establish optional '______-______ ______' for persons with significant health needs who do not qualify by income.
• Prior to SSA, roughly what percent of individuals 65+ had private health insurance?
• What is claims scrubbing?
• Which combination is exempt from most out-of-pocket costs?
• Medicare beneficiary qualifications include being 65 years or older, or under 65 with permanent kidney disease or ALS, or under 65 if permanently disabled. Which option correctly reflects this?
• Which statement best describes the purpose of eligibility verification before claim submission?
• Medicare amendments created to address lack of coverage for older Americans and prevent catastrophic financial impact of serious illness. Which option best describes this dual purpose?
• QPP is an acronym for which program?
• MACRA ended the sustainable growth rate formula which would adjust payments for physicians and suppliers under part ____ in an attempt to manage program spending.
• What is a superbill and when is it used?
• Which HMO type involves physicians employed directly by the HMO?
• Value-Based Purchasing (VBP) incentivizes hospitals for reducing which of the following?
• In a subrogation scenario, which party typically seeks reimbursement from another payer or responsible party?
• For emergency department services, states may maintain copays that are what?
• What are billed charges?
• What is a 'revenue cycle' in medical billing?
• Vulnerable groups (_______ ____ and ______) are exempt from most out-of-pocket costs.
• Which statement best describes how Medicare and Medicaid differ in payment methodology?
• Who is the gatekeeper to HMO networks?
• What is the difference between appealing a denial and resubmitting a claim?
• Fee-for-service payments are an example of which type of payment?
• In networks with binding referral requirements, what must patients do to see a specialist in-network?
• What is the impact of non-participating providers on payments?
• Which entity administers Medicaid at the state level?
• What should medical necessity documentation include?
• Which Medicare Part is primarily responsible for prescription drug coverage?
• Medicare Part C plans may utilize their savings to which of the following for enrollees?
• DMEPOS stands for which of the following?
• EPSDT includes vision coverage for individuals younger than _____ years even in states without vision services coverage.
• How do 'professional claims' differ from 'institutional claims'?
• Medicare Part D required Medicare ______ (Part C) plans to provide Rx drug coverage to their members.
• What is the primary goal of managed care Medicaid?
• Which statement best describes 'usual, customary and reasonable' in payer terminology?
• What is "timely filing" and why is it important?
• Which payments are predetermined but per unit?
• Which funding mechanism provides additional financing to hospitals that serve large numbers of Medicaid, low-income, and uninsured populations?
• What is Part B of Medicare?
• ACA reduced Medicare payments to which type of insurance companies?
• Relative Value Units (RVUs) are composed of which three components?
• Medicare Advantage plans may contract with vision plans to provide what type of benefit?
• Which of the following are applied to determine rates for each PFS service?
• The acronym PMPM in Medicare payments stands for which phrase?
• The term 'Diagnosis Related Groups' is primarily used to determine payment amounts based on which factor?
• Medicare Part C is commonly referred to as Medicare Advantage
• What does binding referral requirements mean in some networks?
• Which HIPAA transaction supports the payer's explanation of benefits and payments to providers?
• Value-Based Purchasing programs focus on improving which outcome most directly?
• Which group of providers is included in Part A billing?
• Medicare Part C premiums are determined by the _____ contracted with CMS.
• Since what year have plans reported their MLRs?
• Do most Medicare Advantage plans have a defined out-of-pocket maximum per CMS?
• What is external appeal and when is it used?
• Is vision care for adults required under federal law?
• HMOs deliver care at a predetermined rate; this describes which term?
• The HMO Act intended to provide care with focus on which type of care at a capitated rate?
• Which format is used to submit institutional electronic claims?
• Does MLR include profit or administrative expenses?
• The SGR problem led to adjustments to physician payments in which direction?
• What is meant by 'clean claim' and how to achieve it?
• What is the difference between a copayment and coinsurance?
• What is a best practice when submitting an electronic 837 professional claim?
• Which of the following best describes the relationship among cost, access, and quality in the iron triangle?
• What does MLR stand for?
• Reimbursements under the PFS include visits, surgical procedures and diagnostic tests, therapy services, and preventative services.
• Who typically evaluates medical necessity when deciding coverage?
• PPS is described as reimbursement-based and applies to which Part facilities?
• PPO contracts specify which to manage care and control costs?
• The federal percentage that matches state Medicaid expenditures is known as what?
• Which description best defines capitation in the context of the material?
• HRRP stands for which program?
• Which factors determine the hierarchy used in coordinating benefits when a member has multiple health plans?
• Which statement accurately describes the Physician Fee Schedule?
• Which funding mechanism targets hospitals serving a high proportion of low-income or uninsured patients?
• In Medicare Advantage plans, the benefit level must be equivalent to Original Medicare at a minimum.
• Which statement is true about Medicaid eligibility?
• What is the primary difference between a managed care organization's HMO and PPO in terms of network access and referrals?
• PFS stands for which of the following?
• Medicare + private insurance = Part ___
• What does "prior authorization" typically require from the provider?
• MIPS stands for which term?
• What is a 'modifier' in CPT coding and why is it used?
• The MLR represents the percentage of ______ used for patient care.
• What is claims aging and how should it be managed?
• Which statement about MLR reporting is accurate?
• The SSA of 1935 established a ____-payment ______ insurance program to improve economic security for the elderly. Which option best completes this phrase?
• Which term describes the process that helps determine which payer pays first for dual-eligible individuals?
• MACRA’s Quality Payment Program includes two tracks. Which pair is correct?
• SSI benefits can be drawn in retirement anywhere between ages 62 and 70, with full benefits at age 65, and higher payments if delayed until age 70. Which set of ages matches this description?
• VBP stands for what?
• Which document is commonly used by professional claims to report a patient's diagnosis and procedures on submission?
• Which HMO model contracts with a network of physicians but does not employ them directly?
• What does PMPM stand for in HMO payments?
• EPOs differ from PPOs in that members cannot go out of network.
• PPOs allow outside-network use to do what?
• The Social Security Act of 1935 was designed to improve economic security for which group?
• Which group of providers bills Part B?
• In HMOs, the gatekeeper's primary role is to coordinate care and authorize referrals.
• The 2010 ACA added requirements for Medicare _____ plans and Part ____ to report their medical loss ratios.
• Which plan type is like a PPO but does not allow out-of-network visits?
• What is the role of an EDI gateway in electronic claim submissions?
• Which term describes the private plans contracted with CMS to administer Original Medicare?
• Which type of plan carves out routine vision services provided by optometrists?
• Private insurance companies assume a ______ if the payments from CMS do not cover the plan's cost.
• Which statement best describes original Medicare's coverage of routine services?
• SSI benefits may also be drawn when there is total and permanent ________.
• Which term describes payments that are a predetermined amount regardless of the intensity of the services?
• The patient or secondary plan is responsible for the remaining ____%.
• Medicare utilizes terms to describe those providing ______ and _______ to Medicare beneficiaries.
• PFS payments are based on what measure that accounts for physician work, practice expense, and malpractice?
• FMAP stands for?
• UCR stands for which phrase?
• The annual Physician Fee Schedule release includes which components?
• Why is correct patient demographic and insurance information critical on claims?
• Which coding standard is used to report diagnoses on professional claims?
• Under MACRA, the two tracks within the Quality Payment Program are MIPS and APMs. Which option correctly states this relationship?
• In HIPAA security practices, what is the role of maintaining a detailed user audit trail?
• What Medicaid benefit matters most to optometrists?
• Capitated per-member-per-month payment describes which option?
• What are the components of the iron triangle of healthcare?
• What term describes the pediatric preventive services coverage required through age 21?
• State Medicaid agencies may receive waivers to contract with managed care organizations.
• DSH stands for?
• If a service is not covered under the plan, which statement best describes patient financial responsibility?
• What is the proper sequence for resubmitting a denied claim?
• Traditional Medicare pays ___% of the approved amount after deductible.
• HMOs cover all services provided to the member.
• How does the "allowed amount" differ from the billed charges in payer adjudication?
• Which program is designed to cover children in families with incomes above Medicaid limits but who cannot afford private coverage?
• A claim submitted after the timely filing deadline is most likely to be denied.
• GRGs stands for which of the following?
• In rare or high-cost therapies, what is the primary purpose of preauthorization?
• In payer policy, the term 'medical necessity' is demonstrated when a service aligns with what?
• Managed care reimbursement models seek to control costs through which combination?
• With Medicare Part C, any savings realized through greater efficiencies and cost controls would be shared between the _______ and ______ ______
• External appeal timelines in practice are typically:
• In 1965, the SSA was amended to create Medicare to address the lack of coverage for older Americans and prevent catastrophic financial impact of serious illness. Which option best describes Medicare's purpose?
• EPSDT stands for what?
• What does HMO stand for?
• In Medicare terminology, PPS stands for which of the following?
• Which age yields higher benefits when SSI benefits are delayed to age 70?
• What is the role of NCCI edits in CPT coding?
• Geographic pricing cost indexes in the PFS are used to do what?
• Which describes an HMO with direct employment relationship with physicians?
• Can you qualify for both Medicare and Medicaid?
• Which Medicare plan contract with vision plans to provide a supplementary benefit?
• What is the role of a Third-Party Administrator (TPA) in payer processing?
• DRGs are what type of bundled payments for episodes of care, based on the diagnoses and the average Medicare resources used to treat them?
• How do Medicare and Medicaid differ in their approach to payment methodology?
• What is 'HIPAA 837' in the context of claims submission?
• The Social Security Act of 1965 established which program to provide medical assistance to eligible individuals?
• PFS is released annually and includes pricing amounts, payment policies, relative value units and geographic pricing cost indexes.
• Since 2014, plans report their MLRs and are subject to penalties if their MLRs do not meet the ____% requirements.
• Which form is typically used for institutional claims to report facility-based services (UB-04)?
• Part B premiums are deducted from SSI benefits.
• Which taxes must be paid for at least 10 years to qualify for Part A without premiums?
• Medicare established ____ _____ to cover healthcare costs under the program.
• Paid PMPM for Parts A and B, and a separate PMPM for Part D, adjusted for demographic and health factors, describes the PMPM payments to which combination of Parts?
• What is an 'EFT' and why is it preferred by many providers?
• Legislation in 1997 and 2003 refined Medicare Part C and provided additional support for ____-income beneficiaries.
• What is a 'COB order' and how is it determined?
• What is Part A of Medicare?
• Which statement best describes the meaning of 'medical necessity' in payer policy?
• What is the common coding standard used to report diagnoses and why is accuracy critical?
• Which denial code indicates that the service was not medically necessary per payer policy?
• Automatic enrollment in Medicare Parts A and B is automatic if the patient receives SSI benefits 4 months before they turn 65.
• Medicare Part C plans are commonly known as what type of plan that contracts with CMS to deliver Part A and Part B benefits?
• What is the difference between subrogation and third-party liability (TPL) in payer recoveries?
• _____ - based contracts shift the healthcare costs for medicare beneficiaries to private insurances where the plan receives a capitated per-member-per month rate
• What are the three exceptions to Medicaid income criteria?
• What is the purpose of attachment requirements with claims?
• What is the difference between an EOB and a RA, and who receives them?
• Michigan uses a request for proposal for managed care Medicaid as a competitive _______ process.
• Which item is least likely to be required as an attachment for claims?
• APM stands for which term?
• Which payer type is typically responsible for payments for services to eligible low-income individuals through state-administered programs?
• Medicaid qualification requirements are determined at the ____ level.
• States can establish copays for which item?
• HMOs are a prepaid system to deliver care at a predetermined rate. Which phrase represents this description?
• What is dual-eligible in Medicare programs, and how does it affect billing?
• How can a payer deny a claim due to a non-covered service?
• Prior to Medicare Part D/Part C, Rx medications were only covered during which Medicare Part?
• SSI stands for which of the following?
• Which Medicare Part is premium-free for those who paid FICA taxes for at least 10 years?
• The HMO Act addressed challenges with what?
• When a patient or spouse is working when they turn 65, they must enroll in Part A and Part B; however, the employer-sponsored insurance plan is the primary payer and Medicare is the secondary payer.
• Under DRGs, which component is used to classify episodes of care?
• Which mechanism reduces payments to Medicare providers automatically?
• The ACA reconstructed which payments with a focus on quality and efficiency and lower hospital admissions?
• Which two HIPAA transaction types are commonly used in third-party payer billing?
• When a denial cites medical necessity, what actions should be taken?
• Which statement correctly describes coordination of benefits hierarchy?
• What items are commonly found on a remittance advice (RA) beyond the claim payment?
• Which Medicaid funding provision provides higher matching rates for states that expanded Medicaid under the ACA?
• Why is provider enrollment with a payer important?
• What was the goal of the ACA regarding Medicare program costs between 2010 and 2015?
• ACA cracked down on fraud, waste and abuse in which program?
• What information is conveyed by the UB-04 Type of Bill designation and why is it important?
• Medicare Part C is commonly referred to as which type of plan?
• CHIP stands for which of the following?
• Are PPOs or HMOs more costly to employers?
• HRRP incentivizes hospitals to reduce what?
• Currently, sequestration reduces medicare payments to providers by ____%
• Which routine services are excluded from Original Medicare coverage?
• In what year did the HMO Act become law?
• Managed care Medicaid plans carve out routine vision or optometry services.
• MACRA developed quality payment programs to replace which program?
• Which component is not typically part of the patient access phase of the revenue cycle?
• Medicare Part D is which of the following?
• What are common payer denial reason codes and how should they be addressed?
• Which program is specifically designed to reduce hospital readmissions?
• Which statement best describes Medicare eligibility as presented?
• How do auto insurance (PIP) and workers' compensation claims differ from standard commercial claims?
• CHIP provides insurance for families above Medicaid income limits yet cannot afford private health insurance.
• Which items are typically confirmed during eligibility verification before submission?
• Which plan type is typically more costly for employers?
• Managed care Medicaid is very similar to which Medicare Part?
• Which statement about claims attachments being not typical is true?
• What was the initial coverage gap in Medicare Part D?
• Following the 1973 HMO Act, 1982 legislation allowed Medicare to contract with ______ health insurance companies to provide Medicare benefits
• In PPO contracts, what term governs utilization management?
• What is the purpose of a 'user audit trail' in the HIPAA/security context?
• What is a remittance advice (RA) and what key information does it contain?
• Which of the following is NOT a type of health maintenance organization (HMO) model?
• Medicare contracts with private health insurers to administer Original Medicare are awarded ______ to process claims, enroll providers, handle appeals, perform audits and establish policies.
• Which funding component reflects state general fund appropriations that cause variation in Medicaid coverage by state?