Interview Questions

1. Ambulatory Surgery (ASC)?

Outpatient surgery or surgery that does not require an overnight hospital stay (more than 24 hours). Other names Day surgery / Same Day Surgery / Short Procedure Unit / SDS.

E.g: Hernia repair, Eye cataract surgery, etc.,

2. Account Number/Encounter #?

The number is given by the doctor or hospital for each and every patient’s medical visit to track what is the

i) medical condition, ii) treatment rendered, iii) Cost of the treatment rendered for that particular date of service. It is in cms box# 26.

3. Advance Beneficiary Notice (ABN) or Waiver Of Liability (WOL)?

A notice the hospital or doctor gives the patient before the treatment, telling the patient that Medicare will not pay for some treatment or services. The notice is given to the patient so that the patient may decide whether to have the treatment and how to pay for it.

Medicare payer uses the name ABN, commercial payers other than medicare will use the name WOL, both ABN and WOL forms are same .

4. Allowed amount / considered amount/Approved amount?

The dollar amount an insurance company deems fair for a specific service or procedure.

5. Authorization Number?

Before providing certain services the provider must receive approval from a staff member of the payer’s UMR dept (Utilization Management Review). It relates not only to the service of the procedure is covered but also to find out whether it is medically necessary. Other names Certification Number/ PriorAuthorization Number / Pre-certification / Pre-admission approval. It’ll be in the CMS 1500 box# 23

6. Beneficiary (OR) Insured Person?

A person eligible for receiving benefits under insurance policy. He is also called as enrolee or insured or subscriber or member

7. Billed amount of the claim/Charge amount of the claim?

It is the provider charge for the services he done. Billed amount vary from provider to provider.

8. Billing Address?

Insurance company EOBs and Cheques received to this address It will be in CMS 1500 Box# 33.

9. Capitation?

It is like a pre-paid cheque that was paid to the provider periodically. Insurance will assign patients, and capitated providers should provide services on every visit of each patient. A common agreement in capitation is called Per Member Per Month (PMPM). In other words, a specified amount is paid periodically to a healthcare provider for a group of specified health services, regardless of the quantity rendered.

10. Clean Claim?

A claim is one which will pass through all front-end edits to the insurance processing units through electronic clearing house.

11. CLIA- (Clinical Laboratory Improvement Amendments)?

CLIA ensures the accuracy, reliability, and timeliness of patient test results, wherever a test is performed. CLIA number is necessary to bill for Lab code (8 series code).

Pathology and Laboratory: 80047 – 89398.

It is 8 digit code but needs to send as 10 digits, with X4 qualifier and “D” at the third position. Example CLIA#: X4 12D345678. Types of CLIA tests:1.CLIA Waived Test and 2. CLIA Non-Waived Test: CLIA# will be in CMS 1500 BOX# 23.

12. CMS 1500 – (Doctor/Professional claim form)?

The Health Care Finance Administration (HCFA), The Center of Medicaid and Medicare Services (CMS) form 1500 It consists of 33 blocks. This is a medical claim form for individual doctors & practices, nurses, and professionals, including therapists, chiropractors, and out-patient clinics.

13. COBRA Insurance – (Consolidated Omnibus Budget Reconciliation Act)?

COBRA was passed by Congress in 1986. A health insurance coverage for those who become unemployed, either voluntary or involuntary termination of employment for reasons other than gross misconduct. Dependents are also covered in COBRA. From unemployment date COBRA will gives Coverage for 18 months and maximum up to 36 months under certain conditions. COBRA does not provide coverage for life insurance and disability insurance.

14. Coinsurance – (Patient responsibility given by payer)?

Coinsurance A percentage the patient is responsible to pay for the cost of the medical services. The patient pays coinsurance after the patient’s deductible has been met. Coinsurance is a way of saying that patient and the patient’s insurance carrier each pay a share of eligible costs that add up to 100 %. For example, Insurance pays 80 % and the remaining 20% is the patient responsibility as coinsurance

15. Contractual Adjustment – (Provider Discount or writeoff or adjust given by payer)?

Contractual Adjustment is the part of the bill that the doctor or hospital must write off (not charge the patient. Contractual Adjustment is the part of the bill that the doctor or hospital must write off (not charge the patient) because of billing agreements with the patient’s insurance company. This is only for contracted providers.

16. COB – (Coordination of Benefits)?

To identify which insurance is primary and which insurance is secondary and which one is tertiary. If the patient has more than one insurance plan, the patient needs to update the COB to both insurances to establish which insurance is primary and which insurance is secondary—the primary payer will pay first and the secondary payer will pay the remaining balance (patient responsibility) after the primary paid.

17. Co-pay- (Patient responsibility given by payer)?

A co-payment is the smallest fixed amount for a covered service, paid by a patient to the provider before receiving the specified service. Generally, Plans with lower monthly premiums have a higher copay. Co-payments such as $5, $10, $15, $20 etc.,

18. CPT – Current Procedural Terminology?

Designed by – American Medical Association (AMA)
Year – 1966
CPT – 5 Digits Numeric, Alpha, Alpha Numeric

Why was the CPT code created?
To standardized reporting of medical, surgical, and diagnostic services and procedures performed in in-patient and out-patient settings.
Example: CPT 99214 denotes an office visit. CPT 90716 denotes the chickenpox vaccine

CPT code entered in CMS 1500 Box# 24D

CPTs are 3 Categories:
Category I – The existing codes
Category II – Supplemental code or tracking code for performance measurements
Category III – Temporary codes for experimental services

CPTs are 3 Levels:
Level I (DOCTOR)
Level II (HOSPITAL)
Level III codes, also HCPCS local codes.

19. Date of Birth Rule (DOB Rule)?

DOB Rule is to decide whose insurance will act as primary to child when mother and father is having insurance policy.

As per DOB rule, Mother’s DOB is August 16 1994 and Father’s DOB is November 9 1991. Since Mother’s birthday comes first in the year (here birth year is not taken also it doesn’t matter how old they are, it is considered whose date of birth comes first in the year), here mother’s birthday will come first so her plan will provide primary coverage for the children, and Father’s will be secondary.

20. Deductible (Patient responsibility given by payer)?

A fixed amount per contractual period that a pt pays before health insurance will begin to pay; this is only paid if provider services are obtained. The patient has to meet the Deductibles every year. It is mostly patient responsibility and very rarely another payer pays this amount.