Medical Office Administration and Billing Flashcards
6 cards from real NCMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Medical Office Administration and Billing flashcards as text
What does the CMS-1500 claim form primarily contain, and who uses it?
Answer: A standardized claim form for professional outpatient services submitted by physicians and non-institutional providers to payers
The CMS-1500 (also called the HCFA-1500) is the standard paper claim form used by physicians, medical practices, and non-institutional providers to submit professional outpatient service claims to Medicare, Medicaid, and most commercial payers.
What is a Coordination of Benefits (COB) scenario in medical billing?
Answer: When a patient has more than one insurance plan and rules determine which pays first (primary) and which pays second (secondary)
Coordination of Benefits (COB) is the process that determines the order in which multiple insurance plans pay when a patient is covered by more than one plan. The primary payer pays first; the secondary payer covers remaining eligible costs.
What is the difference between an HMO and a PPO insurance plan as it affects patient scheduling in a medical office?
Answer: HMOs require referrals for specialist visits and restrict to in-network providers; PPOs allow direct specialist access with out-of-network coverage at higher cost
HMOs (Health Maintenance Organizations) require patients to select a primary care physician (PCP) who coordinates care and provides referrals to specialists. PPOs (Preferred Provider Organizations) allow direct specialist access without referrals and offer out-of-network coverage.
In medical billing, what does the term 'clean claim' mean?
Answer: A claim that is complete, accurate, and contains all required information allowing the payer to process it without requesting additional information
A clean claim is one that passes all payer edits and contains complete, accurate information (patient demographics, valid codes, provider NPI, authorization numbers, etc.) allowing the insurer to process and adjudicate it without returning it for additional information.
What is a National Provider Identifier (NPI), and who requires it?
Answer: A standard 10-digit identifier issued by CMS to all healthcare providers covered under HIPAA for billing purposes
The NPI (National Provider Identifier) is a unique 10-digit identification number issued by the CMS National Plan and Provider Enumeration System (NPPES) to all HIPAA-covered healthcare providers. It is required on all standard healthcare transactions.
A patient hands you their insurance card at check-in, but the information in the EHR shows a different plan from their last visit. What should you do?
Answer: Copy both sides of the new card, update the EHR, verify eligibility and benefits with the payer, and confirm any changes affect the current visit
Insurance information must be verified at every visit. When a patient presents new insurance, update the EHR immediately, copy both sides of the card, and verify eligibility in real time through the payer portal or clearinghouse to confirm current coverage and benefits before the visit.