Athl 235

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ATLH 235
July 16, 2011
Take home Exam

46. Explain the difference between assignments of benefits and accept assignment. Ans: Assignment of benefits is when the provider receives reimbursement directly from the payer while accept assignment is when the provider accepts as payment in full whatever is paid on the claim by the payer. 47. What is the purpose of the new patient interview and check-in procedure? Ans: The purpose of the new patient interview and check-in procedure is to obtain information, schedule the patient for an appointment, and generate a patient record. 48. Explain the difference between a participating provider (PAR) and a nonparticipating provider (non-PAR). Ans: A participating provider (PAR) contracts with a health insurance plan and accepts whatever the plan pays for procedures or services perform while on the other hand a nonparticipating provider (non-PAR) does not contract with the insurance plan, and patients who elect to receive care from non-PARs will incur higher out-of-pocket expenses. 49. When a provider’s office contacts the payer to verify a patient’s insurance eligibility and benefit status, HIPAA privacy standards mandate that four areas of pertinent information be provided. Name them. Ans: Beneficiary last name and first initial, Beneficiary date of birth, Beneficiary health insurance claim number (HICN), and Beneficiary gender 50. Explain primary insurance versus secondary insurance.

Ans: Primary insurance is the insurance plan responsible for paying healthcare insurance claims first. Once the primary insurance is billed and pays the contracted amount, the secondary plan is billed for the remainder, and so on. 51. What is the birthday rule?

Ans: The birthday rule determines coverage by primary and secondary policies when each parent subscribes to a different health insurance plan. 52. What is the gender rule?
Ans: The gender rule is a rule that states that the father’s plan of the child or (dependents) is always primary when the child is covered by both parents.

53. Define encounter form, and distinguish between a superbill and a chargemaster. Ans: Encounter form is the financial record source document used by healthcare providers and other personnel to record treated diagnoses and services rendered to the patient during the current encounter. In the physician’s office an encounter form is called a superbill and in a hospital the encounter form is called chargemaster. 54. What is the patient ledger?

Ans: Patient ledger is a permanent record of all financial transactions between the patient and the practice. 55. Define a day sheet.
Ans: Day sheet is a chronologic summary of all transactions posted to individual patient ledgers/ accounts on a specific day. 56. What is a clearinghouse?
Ans: A clearinghouse is a public or private entity that processes or facilitates the processing of nonstandard data elements into standard data elements. 57. List some examples of covered entities.

Ans: Worker’s Compensation, Military Health Systems, HealthCare clearinghouses, and Indian Health services

58. What is a claims attachment?
Ans: A claim attachment is a set of supporting documentation or information associated with a healthcare claim or patient encounter. 59. What does the claims adjudication process verify?
Ans: The claims adjudication process verify that the required information is available to process the claim, claim is not a duplicate, payer rules and procedures have been followed and procedures performed or services provided are covered benefits. 60. Explain allow charges.

Ans: Allow charges are the maximum amount the payer will allow for each procedure or service, according to the patient’s policy. 61. What is meant by the statement “to link the diagnosis with the procedure/service”? Ans: The statement “to link the diagnosis with the procedure/service means to match up the...
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