#1
What is a pre-authorization in healthcare insurance claims processing?
A request for medical treatment before it's performed
ExplanationRequesting approval for medical procedures beforehand.
#2
What does the term 'co-payment' refer to in healthcare insurance?
The amount paid by the insured for covered services
ExplanationThe portion of expenses the insured pays for covered services.
#3
Which of the following is a common reason for a healthcare insurance claim denial?
Inaccurate patient information
ExplanationErrors or discrepancies in patient information leading to denial.
#4
In healthcare insurance, what does 'EDI' stand for?
Electronic Data Interchange
ExplanationElectronic exchange of healthcare information between parties.
#5
What does 'EOB' stand for in healthcare insurance?
Explanation of Benefits
ExplanationStatement detailing what medical services were paid for.
#6
What is DRG in the context of healthcare insurance claims?
Diagnostic Related Group
ExplanationGrouping patients based on similar diagnoses for billing purposes.
#7
Which organization oversees the implementation of HIPAA regulations in the US?
Office for Civil Rights (OCR)
ExplanationResponsible for enforcing HIPAA privacy and security rules.
#8
What is the role of a claims adjuster in healthcare insurance?
To investigate and evaluate insurance claims
ExplanationEvaluating the validity and accuracy of insurance claims.
#9
What is a CMS-1500 form used for in healthcare insurance claims processing?
To submit claims for healthcare services
ExplanationSubmitting claims for healthcare services to insurers.
#10
What is meant by 'coordination of benefits' in healthcare insurance?
The process of managing multiple insurance policies to maximize coverage
ExplanationManaging multiple insurance policies to optimize coverage.
#11
What is the purpose of a clearinghouse in healthcare insurance claims processing?
To process electronic claims before they are sent to insurers
ExplanationProcessing electronic claims for accuracy before submission.
#12
What is 'coding' in the context of healthcare insurance claims?
Assigning alphanumeric codes to diagnoses and procedures
ExplanationUsing codes to categorize diagnoses and procedures for billing.
#13
Which organization is responsible for overseeing the implementation of ICD codes in the US?
Centers for Medicare & Medicaid Services (CMS)
ExplanationOverseeing the use and updates of diagnostic codes in healthcare.
#14
What is 'medical underwriting' in the context of healthcare insurance?
The process of assessing a patient's medical history and risk factors
ExplanationAssessing a patient's medical history and risks for insurance purposes.