CMAA NHA Certified Medical Administrative Assistant - Set 4 - Part 3

Correct Answer: Referral

A referral is a formal recommendation from a primary care provider to a specialist, often required by HMO and POS plans for coverage, and it is communicated through the payer's portal or by fax. Option a is incorrect because predetermination is a non-binding estimate of likely benefit for a planned service, used for elective procedures rather than the formal recommendation to see a specialist that defines a referral. Option b is incorrect because an advance directive describes the patient's wishes about life-sustaining treatment during incapacity, which is unrelated to the formal recommendation to see a cardiologist that this scenario describes. Option c is incorrect because the Universal Protocol covers pre-procedure surgical safety steps, which is unrelated to the formal recommendation to see a specialist that the patient's primary care provider is sending in this case.

Correct Answer: Precertification or preauthorization

Precertification or preauthorization confirms that the proposed service is medically necessary and will be covered under the patient's plan, with an approval number, valid dates, units approved, and specific procedures listed for the service. Option b is incorrect because the Advance Beneficiary Notice informs Medicare patients about possible non-coverage of a specific service rather than the prior approval submitted to a payer for elective imaging in this scenario. Option c is incorrect because the Notice of Privacy Practices describes how protected information may be used and disclosed under HIPAA rather than the prior approval submitted to a payer for the specific imaging service in this scenario. Option d is incorrect because code of conduct certification is unrelated to insurance approval workflows, since the CMAA's submission concerns prior approval of a planned service rather than personnel certification at the practice.

Correct Answer: Predetermination of benefits

Predetermination of benefits is a non-binding estimate by the payer of the likely benefit for a planned service, used for some elective procedures and helpful for planning even though it does not bind the payer. Option a is incorrect because sentinel event analysis is a Joint Commission process for serious adverse outcomes, which is unrelated to the non-binding payer estimate the practice submits before an elective procedure today. Option b is incorrect because hospital incident reports document unusual events for risk management, which is unrelated to the non-binding payer estimate the practice submits before an elective procedure during this scenario. Option d is incorrect because OASIS home health assessment is a Medicare-required clinical assessment for home health services, which is unrelated to the non-binding payer estimate the practice submits in this elective-procedure scenario.

Correct Answer: NCDs; LCDs; commercial policy; documentation

Medical-necessity criteria come from National Coverage Determinations, Local Coverage Determinations issued by Medicare Administrative Contractors, commercial payer policies, and the clinician's documentation, which together determine whether a specific service is supported by the diagnosis. Option a is incorrect because television ads, flyers, and emails are not authoritative sources of medical-necessity criteria; coverage determinations come from formal payer policy and clinician documentation rather than marketing communications. Option c is incorrect because patient hobbies and weekly menus are unrelated to medical-necessity criteria, which are based on coverage determinations and clinical documentation rather than personal lifestyle items in the patient's life. Option d is incorrect because random survey results and focus groups are not authoritative sources of medical-necessity criteria; coverage determinations come from formal payer policy and clinician documentation r

Correct Answer: Expired auth; wrong CPT; insufficient units

Common authorization pitfalls include expired authorizations, the wrong CPT code listed, insufficient units approved, the wrong provider on the authorization, missing referrals, and services performed before authorization is received. Option a is incorrect because calm tone, clean uniform, and punctuality are aspects of professional presence rather than authorization workflow pitfalls, so they do not match the post-mortem topic the team is reviewing today. Option b is incorrect because snacks, pet photos, and jokes are unrelated to the authorization workflow and are not part of the documented pitfalls the team is reviewing during this post-mortem at the practice. Option c is incorrect because music, flowers, and candles are unrelated to the authorization workflow and are not part of the documented pitfalls the team is reviewing during this post-mortem at the practice today.

Correct Answer: ICD-10-CM diagnosis code set

ICD-10-CM codes diagnoses, signs, symptoms, and reasons for visits with three to seven alphanumeric characters, including a letter first, used across all health care settings to support medical necessity and billing. Option b is incorrect because CPT codes professional services and procedures with a five-digit numeric format for Category I codes, which is a different code set than the diagnosis-focused ICD-10-CM described in this scenario. Option c is incorrect because HCPCS Level II codes products, supplies, and services not in CPT with a one-letter plus four-digit format, which is a different code set than the diagnosis-focused ICD-10-CM described. Option d is incorrect because the National Drug Code is an eleven-digit code identifying specific drugs by labeler, product, and package size, a different code set than the ICD-10-CM diagnoses described.

Correct Answer: Modifier 95 for synchronous video telehealth

Modifier 95 indicates synchronous telehealth via real-time interactive audio-video technology, with modifier 93 used for synchronous audio-only telehealth, and place-of-service codes capturing the location element of the encounter. Option a is incorrect because modifier 25 indicates a significant, separately identifiable evaluation and management service on the same day as a procedure, which is a different modifier from the telehealth modality marker described. Option b is incorrect because modifier 50 indicates a bilateral procedure performed on both sides during the same encounter, which is a different modifier from the telehealth modality marker described in this scenario. Option d is incorrect because modifier LT indicates a left-side procedure as a laterality marker, which is a different modifier from the telehealth modality marker described in this scenario for an interactive audio-video visit.

Correct Answer: Advance Beneficiary Notice

The Advance Beneficiary Notice is the CMS form given to original Medicare beneficiaries before a service that may not be covered, allowing the patient to choose to proceed and accept financial responsibility if Medicare denies. Option a is incorrect because the Notice of Privacy Practices describes how protected information may be used and disclosed under HIPAA, which is a privacy notice rather than the Medicare medical-necessity notice described in this scenario. Option c is incorrect because the Universal Protocol checklist supports surgical safety with pre-procedure verification, site marking, and time-out, which is unrelated to Medicare medical-necessity notification at the start of an outpatient service. Option d is incorrect because the Assignment of Benefits authorizes the insurer to pay the practice directly, which is a billing form distinct from the Medicare medical-necessity notice described in this scenario today at the practice.

Correct Answer: Explanation of Benefits

The Explanation of Benefits is the payer's statement to the patient summarizing how a claim was processed, including allowed amount, plan paid amount, patient responsibility, and reason codes, plus the note that it is not a bill. Option a is incorrect because the ICD-10-CM coding manual is a coding reference for assigning diagnosis codes, which is a different document from the patient-facing claim summary described in this scenario at the practice today. Option b is incorrect because an OSHA hazard label appears on chemical containers in workplaces, which is unrelated to a patient-facing claim summary describing how a claim was processed by the insurance company. Option c is incorrect because a Joint Commission survey letter relates to accreditation activities, which is unrelated to the patient-facing claim summary that the patient has received from her insurance company today.

Correct Answer: Eight-three-five Electronic Remittance Advice

The eight-three-five transaction is the Electronic Remittance Advice, detailing payment dates, allowed and paid amounts, adjustment reason codes, and remark codes, often paired with electronic funds transfer for streamlined posting at the practice. Option a is incorrect because the two-seventy transaction is an eligibility and benefit inquiry, used to ask the payer about coverage and benefits rather than to communicate the result of a processed claim. Option c is incorrect because the two-seventy-one transaction is an eligibility and benefit response, used to send the payer's reply about coverage and benefits rather than to communicate the result of a processed claim back. Option d is incorrect because the two-seventy-eight transaction is a health care services review, used for authorization requests and responses rather than to communicate the result of a processed claim back to the practice.