CCA Medical Claims and Healthcare Coverage 1 — Questions and Answers
Question 1: What does 'ICD' stand for in the context of medical billing used in claims processing?
- International Classification of Diseases (Correct answer)
- Insurance Claims Documentation
- Integrated Claims Database
- Itemized Cost Details
Correct answer: International Classification of Diseases
ICD (International Classification of Diseases) is the standard worldwide system used by healthcare providers to code diagnoses on medical bills submitted for reimbursement.
Question 2: What are CPT codes primarily used to identify in medical billing?
- Patient demographic information
- Diagnosis and disease classification
- Medical procedures and services performed (Correct answer)
- Insurance policy numbers
Correct answer: Medical procedures and services performed
CPT (Current Procedural Terminology) codes identify the specific medical procedures and services performed by healthcare providers, telling insurers what was done rather than why.
Question 3: An Independent Medical Examination (IME) is typically ordered by an insurance adjuster to:
- Provide free medical care to claimants
- Obtain an objective assessment of the claimant's medical condition and treatment (Correct answer)
- Replace the claimant's treating physician
- Determine the claimant's insurance coverage limits
Correct answer: Obtain an objective assessment of the claimant's medical condition and treatment
An IME provides an independent, objective medical opinion about the nature, extent, and causation of injuries, helping adjusters make informed decisions about claim validity and value.
Question 4: What is a 'superbill' in medical claims processing?
- An invoice for extremely high-cost medical procedures
- A detailed itemized statement of medical services and their billing codes (Correct answer)
- A bill sent directly to the patient's employer
- A summary of all claims filed by a claimant in one year
Correct answer: A detailed itemized statement of medical services and their billing codes
A superbill is a comprehensive itemized form listing all services provided during a medical visit along with their corresponding diagnosis and procedure codes, used for insurance billing.
Question 5: Medicare Set-Aside (MSA) arrangements in workers' compensation and liability claims are designed to:
- Provide additional income to injured workers
- Protect Medicare's interest by reserving funds for future Medicare-covered medical expenses (Correct answer)
- Reduce the total settlement amount paid to claimants
- Transfer liability from the insurer to Medicare
Correct answer: Protect Medicare's interest by reserving funds for future Medicare-covered medical expenses
MSAs protect Medicare's financial interests by ensuring a portion of settlement funds is set aside to cover future medical expenses related to the injury that Medicare would otherwise pay.
Question 6: What is the primary purpose of a medical bill audit in claims handling?
- To deny all medical claims without review
- To identify billing errors, duplicate charges, and non-covered services to ensure payment accuracy (Correct answer)
- To determine fault in an accident
- To verify the claimant's prior insurance history
Correct answer: To identify billing errors, duplicate charges, and non-covered services to ensure payment accuracy
Medical bill audits identify overbilling, unbundling, duplicate charges, and non-covered services, ensuring the insurer pays only for legitimate, accurately billed medical care.
Question 7: Coordination of Benefits (COB) is a process used when:
- A claimant files claims with multiple attorneys
- A claimant has coverage under more than one health insurance plan (Correct answer)
- An adjuster coordinates with multiple repair facilities
- Two insurers dispute liability for an accident
Correct answer: A claimant has coverage under more than one health insurance plan
COB establishes how multiple health insurance plans share the cost of a medical claim when a person is covered by more than one plan, preventing duplicate or excessive payments.
CCA Medical Claims and Healthcare Coverage 1
What does 'ICD' stand for in the context of medical billing used in claims processing?