For AR Interview Questions and Answers

01. Tell me about you self. (Minimum duration is 3 mins).

02. Please ask Roles and responsibility for each company. (Minimum duration is 3 mins for each
company).

What is Medicare and who is eligible for MCR?

Medicare is a U.S. Federal government program which pays for certain health care services rendered
to:
 The Persons 65 years and over.
 The Disabled (not gainfully employed for 24 months)
 Diagnosed with the permanent kidney failure End Stage Renal Disease (ESRD).
 All individuals above 65 years of age are eligible for Medicare. However, a person can get
Medicare Part A for FREE or by paying a certain PREMIUM.
PART A (HOSPITAL INSURANCE)
Part A is hospital insurance that pays the costs of a stay in a hospital or skilled nursing facility, home
health services or hospice care.
This hospital insurance plan is financed mostly through taxes on employers and employees. Persons
who qualify for Medicare receive Part A automatically (they don’t need to purchase Part A)
Part B (Medical Insurance)
Part B is medical insurance that pays for doctor’s services, outpatient hospital services, durable
medical equipment, outpatient hospital care, Physical and Occupational therapies and other medical
services and supplies not covered by Part A.
Part B has a monthly premium, deductibles and co-payments. The beneficiary is responsible for the copay
amount unless covered by a Medicare supplemental insurance plan.
Note: Persons who
What is Medicaid and who is eligible for MCD?
Medicaid is funded by state and federal taxes. Within certain federal guidelines, each state operates its
own Medicaid program. Thus, each state’s Medicaid program has its own features, benefits, costs, and
regulations. Medicaid originated from Title XIX of SSA of 1965. It is a Federal-State matching entitlement
program that pays for medical assistance for needy individuals and families with low incomes and
resources. Eligibility depends on a family's income - Family income vs. Federal Poverty Level (FPL) Note:
Medicaid does not provide medical assistance for all poor persons.
Advanced Beneficiary Notice: An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a
notice you should receive when a provider or supplier offers you a service or item they believe Medicare
will not cover
In-network Co-payment
A fixed amount (for example, $15) you pay for covered health care services to providers who contract with
your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
Out-of-network Co-payment
A fixed amount (for example, $30) you pay for covered health care services from providers who do not
contract with your health insurance or plan. Out-of-network co-payment’s usually are more than in-
network co-payments.
What is the EOB?
This is a document that is sent across as a communication of decision from the insurance to the
Provider’s billing office stating whether the Claim submitted is paid or denied.
It is called by several names such as Provider vouchers / ERA-Electronic Remittance Advice / Statement
of benefits / etc.

What is CONTRACTUAL ADJUSMENT or (CO45):

The difference between billed amount and allowed amount is called as contractual adjustment. The
provider should not collect this amount from the patient. This has to be adjusted off as the Physician is
participated/contracted with Insurance carrier.
When Medicare is secondary Payer?
Sever cases Medicare is secondary payer
1. Working Aged (Medicare beneficiaries age 65 or older) and Employer Group Health Plan (GHP):
2. Disability and Employer GHP:
3. End-Stage Renal Disease (ESRD):
4. Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) – the law that provides continuing
coverage of group health benefits to employees and their families upon the occurrence of certain
qualifying events where such coverage would otherwise be terminated.
5. Retiree Health Plans
Individual is age 65 or older and has an employer retirement plan:
Medicare pays Primary, Retiree coverage pays secondary
7. Workers’ Compensation Insurance
ADVANCE BENEFICIARY NOTICE: ABN :
An ABN is a written notice from Medicare Provider, given to patient before receiving certain items or
services, notifying the patient:
Medicare may deny payment for that specific procedure or treatment.
The patient will be personally responsible for full payment if Medicare denies payment.
What is the Allowed Amount
Maximum amount on which payment is based for covered health care services. This may be called “eligible
expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed
amount, you may have to pay the difference.
CLIA – Clinical Laboratory Improvement Amendment:
It establishes the quality standards for all the laboratories testing to ensure accuracy, reliability and
timeliness of patient test results. CLIA number is used while reimbursement of lab charges.

NDC – National Drug Code:

The NDC is a unique product identifier used in the United States for drugs intended for human use. NDC is
a unique 10-digit, 3-segment numeric identifier assigned to each medication listed.

Global Period:
A global period is a period of time starting with a surgical procedure and ending some period of time after
the procedure. Many surgeries have a follow-up period during which charges for normal post-operative
care are bundled into the global surgery fee.
Managed Care Plan
A person's care is managed by limiting the providers a subscriber can visit. The premiums are usually
lower than commercial insurance. Usually managed care pays a larger portion of a patient's bill than
commercial insurance by limiting choices in providers to those providers who discount their services.
Types of Managed Care Plans
Managed Care Plan, please can you explain about plans?
There are three common types of managed care plans –
 Health Maintenance Organization (HMO)
 Point of Service (POS)
 Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)

HMO plans are usually the least expensive managed care plans because they have the most restrictions
on provider choice. An HMO consists of a network of physicians, hospitals, and other providers that
have contracted with an insurance company to manage a subscribers' care. If a patient goes to a
provider who is not in network (out of network) then the claim is denied.

In an HMO, a patient must first see a Primary Care Physician (PCP) who serves as the initial contact
between the patient and the medical system. The PCP manages the patient's care and refers to a
specialist or other provider as necessary.

Referral — this is a reimbursement requirement of HMO plans where a patient must first be referred by
a PCP before the specialist or the hospital's services will be covered. The patient is given a referral
number by the PCP, which is to be collected by the facility provider or specialist.
Point of Service (POS)

In a POS plan, Members have the option of staying within their product network or "flexing" out of it. If
the member stays within the product network, the plan will act like a regular HMO plan (will require
PCP referrals, etc); however, if they go out of the network, no PCP referral will be required, but a
higher patient responsibility may apply.

Preferred Provider Organization (PPO)

PPO plans give patients the most choice in providers, but are usually the most expensive for patients.
PPO plan allows choosing any doctor or hospital that accepts PPO without a written referral from your
PCP. But if an out-of-network physician or hospital is chosen, then a higher patient responsibility is
applied. This provider group is generally much larger than the network in an HMO and POS. With PPO, a
patient's care is not managed by a PCP. The patient will not need a referral to see a specialist.
What is the CPT code and CPT Ranges?
The Current Procedural Terminology (CPT®) codes offer doctors and health care professionals a uniform
language for coding medical services and procedures to streamline reporting, increase accuracy and
efficiency.
Level I CPT code classification
Nature of Treatment Code Category
Anaesthesiology 00100 to 01999
Anaesthesiology 99100 to 99140
surgery 10040 to 69990
Radiology 70010 to 79999
Pathology and Laboratory 80049 to 89399
Medicine 90281 to 99199
Evaluation and
99201 to 99499
Management

What is Pre-certification?
The formal process of obtaining certification or authorization for healthcare services. Often involves
appropriateness review against criteria and assignment of length of stay for inpatient care.

What is the Hospice, and please can you explain modifier GV and GW.
Facility or program engaged in providing palliative and supportive care of the terminally ill. They are
licensed, certified or otherwise authorized pursuant to the law of jurisdiction where services are provided.

The GV and GW modifiers are used for Medicare hospice patients. The GV modifier is used to report
services related to a patient's hospice care, while the GW modifier is used to report services that are
unrelated to the patient's hospice care.

What is offset: It is the process of adjusting the overpaid amount on future claims/next transactions by
Insurance. In case the insurance company makes an excess payment, the incorrectly paid amount is
adjusted in the next transaction of the provider, Here the next transaction means the next claim that
is received from the provider and it need not be for the same patient.

What is Modifiers, please can you explain few, modifier:

• Two digit codes that further explain the HCPCS codes. In other words they further describe the
service done to the patient.
• Example: A modifier explains whether an X-ray was done to the right hand or left hand.
Note:
• Every HCPCS code need not have a Modifier
• One HCPCS may have multiple modifiers
21- Prolonged E & M Services: When the face-to-face or floor/unit service(s) provided is prolonged or
otherwise greater than that usually required for the highest level of evaluation and management (E&M)
service within a given category.
22- Unusual Procedural Services: When the service(s) provided is greater than that usually required for the
listed procedure. Note: This modifier is not to be used to report procedure(s) complicated by
adhesion formation, scarring, and/or alteration of normal landmarks due to late effects of prior surgery,
irradiation, infection, very low weight (neonates and infants less than 10 kg.) or trauma.

23- Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local
anesthesia, because of unusual circumstances, must be done under general anesthesia.

24- Unrelated E&M Service, Same Physician, During Postoperative

Period: The physician may need to indicate that an E&M service was performed during a postoperative
period for a reason(s) unrelated to the original procedure.

25- Significant, Separately Identifiable E&M Service by the Same Physician on the Same Day of the
Procedure or Other Service:
The physician may need to indicate that on the day a procedure or service identified by a CPT code was
performed, the patient’s condition required a significant, separately identifiable E&M service above and
beyond the other service provided or beyond the usual preoperative and postoperative care associated
with the procedure that was performed. The E&M Service may be prompted by the symptom or
condition for which the procedure was provided. As such, different diagnoses are not required for
reporting the E&M services on the same date. The circumstance may be reported by adding modifier 25 to
the appropriate level of E&M service
Place of Service Codes
• Place of Service Codes are two-digit codes placed on health care professional claims to indicate
the setting in which a service was provide Eg: Following are the few POS codes used to indicate the place of
service
 11: Providers Office
 12: Home Health
 20: Urgent Care
 21: Inpatient Hospital
 22: Outpatient Hospital
 23: Emergency Room
 24: Ambulatory surgical Care
 32: SNF
 Please can you explain RCM cycle?

What is the Cost Sharing?

A general set of financing arrangements via deductibles, co-pays and/or co insurance in which a member
pays some of the costs to receive care. Also see Co-payment, Co-insurance and Deductible.

01. Co-payment:- A cost-sharing arrangement in which a member pays for a specific

Service (e.g., $15 for an office visit) when service is rendered. A typical copay is a fixed amount
For an office visit, prescription or hospital service.
02. Co-Insurance:- The portion of covered healthcare costs paid by the member, usually according
To a fixed percentage. Co-insurance often applies after first meeting a deductible requirement.
03. Deductible:- A predetermined amount of eligible expense, designated by the subscriber’s policy,
That a member must pay each year from his/her own pocket before the plan will make payment
For eligible benefits.
 Denials and action
Claim denied for untimely filing

 Date of denial

 Verify timely filing limit for the payer

 Check the initial claim filed within the TFL or not or proof of Timely Filing.

 If claim billed with in the TFL, need send back for processing or we have POTFL need to submit

reconsideration along with POTFL. (PROFF OF TIMELY FILING LIMIT)

 Fax# to appeal

 TFL to appeal or to send corrected claim

 Re-filing and appealing address

 Fax number.

 May I have the denial date and the filing limit for this claim?

 Can I have the address where I need to appeal for this claim?

 Could you please give me the fax # and can I go ahead and fax it to your attention?

Claim denied for non-covered services

 Date of denial

 Details of the non-covered service.

 Check if the same service paid on other claims

 Check if patient can be billed if it is a non-covered service per the patient’s plan.

 If the service denied as NCS for provider contract, review to appeal.

 TFL to appeal or to send corrected claim

 EOB request.

 Check if there is secondary insurance and they pay it.

 May I have the denial date for this claim?

 Could you please tell me the services that are not covered under this plan?

 Can we go ahead and bill the patient for this claim?

  Can I get a copy of this EOB faxed / mailed to me please?

Claim denied for COB (Co-ordination of Benefits)

 Date of denial

 Information of the other insurance if they have on their file

 Check the claim history to see whether the other claims were paid and paid them.

 Need to Verify with Representative any other insurance active at the time of service, if active need

to bill that insurance.

 Set to patient follow-up if required

 TFL to appeal.

 EOB request

 May I have the date this claim was denied?

 Would you be able to tell me if the patient has any other Insurance?

Could you fax / mail me a copy of the EOB?

Claim denied for authorization number

 Date of denial

 Check if the service require authorization at all.

 Check if there is any auth in the software mentioned for the dos

 Check if they(payer) have an authorization on file for any hospital claim for the same dos

 If authorization found, need to send back for processing, if no authorization found, need send

reconsideration with medical Records.

 For Reconsideration need to take PO BOX address, attn.: and Fax number

 TFL to appeal or to send corrected claim.

 If no EOB found, need to request.

 May I have the date this claim was denied?

 Could you please tell me if you see any authorization # for the same DOS for the hospital claim?
  I have a authorization # in the system, could you re-process the claim if I give this number to you

now?

 Would you be able to re-process this claim if I were to fax you the claim with authorization

number?

 Could you fax / mail me a copy of the EOB?

Claim denied for referral

 Date of denial

 Check if there is any referral on the software mentioned for the dos

 Check if provider is participating and referral require at all.

 If yes, ask for PCP’s name and phone number to contact. (set to client review for PCP follow up)

 Fax number

 TFL to appeal or to send corrected claim

 EOB request.

 May I have the date this claim was denied?

 I have a referral # in the system, could you re-process the claim if I give this number to you now?

 Would you be able to re-process this claim if I were to fax you the claim with referral number?

 Could you fax / mail me a copy of the EOB?

Claim denied as bundled/ incidental/ inclusive

 Date of denial

 Major procedure to which it has been bundled

 Check if the service paid on other claims and Dx combination.

 Need to verify member history any claims are billed with Same DX Codes.

 Can we appeal with medical notes?

 Fax number

 TFL to appeal or to send corrected claim

  EOB request.

 Check if there is secondary insurance and they pay it.

 May I have the date this claim was denied?

 Could you please tell me to which major procedure the claim has been bundled to?

 Can I have the address where I need to appeal for this claim?

 Could you please give me the fax # and can I go ahead and fax it to your attention?

Claim denied as not medically necessary

 Date of denial

 Check why insurance think the service is not medically necessary.

 TFL to appeal or to send corrected claim.

 Claim # and Ref# for correspondence

 Appeal with medical notes

 Fax number

 EOB request

 May I have the date this claim was denied?

 Can I go ahead and send the appeal with medical notes?

 Can I have your fax number please?

 Could you fax / mail me a copy of the EOB?

Claim denied for incorrect modifier

 Date of denial

 Correct modifier

 Please ask what is the modifier, which modifiers are you worked, can you explain about that.

 TFL to appeal or to send corrected claim.

 Claim # and Ref# for correspondence.

 Ask for fax number

 EOB request

 May I have the date this claim was denied?

 Could you please tell me which correct modifier for this procedure is?

 Can I have your fax number please?

 Could you fax / mail me a copy of the EOB?

 What is the modifier and what kind modifiers you worked?

Answer: Modifier provides the means to report or indicate that a service or procedure has been
performed and altered by some specific circumstance but not changed in definition.