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IHMO chapter 8&9 true or false

true
the exchange of data in a standardized format through computer systems is known as electronic data interchange
true
encrypted data often look like gibberish to unauthorized users
false
a batch of claims is a group of claims for different facilities that are sent to the same clearing house
true
the objective of HIPAA transactions and code set regulations was to standardize code sets, claim forms, and processes used in the health care facilities which would reduce administrative costs
false
a disadvantage of electronic claims submission is more time spent processing claims, which requires additional staffing
false
any provider who submits claims to Medicare is considered a covered entity
true
CPT, ICD-9, and HCPCS codes are referred to as medical code sets and are standardized under HIPAA
true
certain data elements are required when submitting a HIPAA standard transaction, whereas other are only necessary in specific situations
false
the American Medical Association (AMA) developed the standards for electronic data exchange
true
the 837P is the National Standard Format for electronic claims submission by physicians, which replaces the paper CMS-1500 form
false
the newest version of electronic claims submission is known as 6020 and was required effective February 1, 2012
false
the National Provider Identifier identifies each individual health plan and is required on all claims as of May 23, 2007
true
encounter form’s procedure and diagnostic codes should be audited annually to determine if code changes have been made and if the form needs to be updated accordingly
false
the most important function of a practice management system is coding of claims submission
true
for insurance claims to be submitted electronically, a signed agreement by the physician with the carriers involved is necessary
true
health care providers must comply with electronic fund transfer rules by January 1, 2014
false
electronic remittance advisories are sent to physicians following electronic funds transfer. However, the staff must still manually post payments to each individual patient’s account
true
practice management systems can be “rented” from practice management systems over the internet
false
clearinghouses always charge a flat fee for claim processing
false
confidential data should be stored only in the computer’s hard drive
false
time limits stated in individual health insurance policies about an insurance company’s obligation to pay benefits are the same for all insurance companies
false
there is a standardization of format for the explanation of benefits document for all private insurance carriers
true
the insurance industry is protected by a special exemption from the Federal Trade Commission
true
insurance companies are rated according to the number of complaints received about them
true
the status of electronic insurance claims may be accessed quickly electronically or telephonically by digital response systems
true
inquiries about insurance claims may be in writing or by telephone
false
a rejected insurance claim should be corrected and sent for review or appeal
false
approximately 50% of individuals pursue appeals on a denied insurance claim
true
in the case of a Medicare Part B redetermination, carriers have been instructed to pay an appealed insurance claim if the cost of the hearing process is more than the amount of the claim
false
if you have a denied insurance claim, you should change the information and resubmit the claim
true
routine use of too many nonspecific diagnostic codes may result in downcoding
true
in any type of overpayment situation, always cash the third-party payer’s check and write a refund check payable to the originator of the overpayment
true
if the provider is notified by a commercial insurance carrier that an overpayment has been made, investigate the refund request
true
a level 1 Medicare redetermination (appeal) may be made by telephone, in writing, or by submitting a CMS-20027 form
false
a peer review is usually done before the appeal process
true
appeal decisions on Medicare unassigned insurance claims are sent to the patient
false
the highest level of a Medicare redetermination is with an administrative law judge

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