COMMONLY ASKED MEDICAL BILLING AR INTERVIEW QUESTIONS 2023

1. What is the Medicare Part B annual deductible for 2023.

Ans. Part B annual deductible is $226.03

2. What is Capitation?

Ans. Capitation is an agreement between the insurance company and the provider as per that insurance
company provider fix amount to the provider per member per month.

3. What is EOB in medical billing?

Ans. Financial Statement which contains payment or denial information.

4. What is Difference between Balance Bill and Contractual Adjustment?

Ans. Contractual Adjustment: CO45

Difference between the Billed amount and the Allowed amount in case of a participating provider

Balance Bill: (This is Patient Responsibility)

Difference between the Billed amount and the Allowed amount in case of a non-participating provider.

5. What is the Difference between recoupment and offset?

Ans. Recoupment:

Recoupment is a request for a refund when Insurance overpays a claim.

Offset:

If the doctor did not refund overpayment then insurance adjusts overpayment in the next claims.

6. What is COBRA ?

Ans. COBRA: Consolidated Omnibus Budget Reconciliation Act

This is a federal act under which employees can continue his previous company insurance for a
Maximum of 18 Months by paying the premium.

7. What is sequestration?

Ans. 2 percent Reductions are done by Medicare from the paid amount which needs to be a write-off.

8. What is COB: Coordination of Benefits ?

Ans. This is the process by which a health insurance company determines if it should be the primary or
secondary payer of medical claims for a patient who has coverage from more than one health insurance
policy.

or
If the patient has more than one insurance he needs to inform the insurance which insurance will act as
primary secondary or tertiary.

9. What is modifier 24, 25 and 59 ?

Ans. Modifier 24 because the E/M service is unrelated and during the post-op period of the surgery.

Modifier 25 to show the E/M is significant and separately identifiable from the procedure

10. What is difference between denial and rejection ?

Ans. Claim rejection occurs before the claim is processed and most often results from incorrect data.
Conversely, a claim denial applies to a claim that has been processed and found to be unpayable.

11. What is the QW modifier used for?

Ans. Modifier QW to indicate that a test is CLIA-waived and the reporting physician’s practice has a CLIA
certificate that allows the physician to perform and report CLIA-waived tests.

12. What is a taxonomy code?

Ans. A taxonomy code is a code that describes the Provider or Organization’s type, classification, and the
area of specialization.

13. What is taxonomy code in CMS form?

Ans. A taxonomy code describes the Provider or Organization’s type, classification, and area of
specialization. For billing purposes, the taxonomy code is entered into Field 24J Grey on the CMS-1500
form.

14. What is POS 11, 12, 21 ?

Ans. 11 Office visit

12 Home visits

21 Inpatient Hospital

23 Emergency Room – Hospital

15. What is the birthday rule in New York?

Ans. Birthday Rule: This is a method used to determine when a plan is primary or secondary for a
dependent child when covered by both parents’ benefit plan. The parent whose birthday (month and
day only) falls first in a calendar year is the parent with the primary coverage for the dependent.

16. What is UB claims?

Ans. The term ‘UB’ in the UB-04 stands for Uniform Billing.

17. What is inclusive denial ?

Ans. When the payment of one CPT is included in the payment of other CPT we get such kind of denials.
We will check on Encoder Pro whether CPT are inclusive or not If found CPT is inclusive, we will send the
claim for coding review.

If found CPT is not inclusive, we need to call insurance and ask a representative to reprocess the claim.

We will take a turnaround time and call Reference.

The modifier used in inclusive denial:

1. 59-Distinct Procedure Service

2. 25-Significiant, Separately Identifiable Evaluation and Management.

Note: If the CPT are not inclusive we can also appeal with medical Record, Screen Shot of Encoder Pro
And EOB.

18. What is Global inclusive denial?

Ans. It includes all the expenses of surgery, pre and post evaluation and management service under
global Period:

We will call to insurance and take Denial Date and Claim Number.

We will ask what Date of Surgery is.

What is the global period?

1st Condition

If DOS falls under the global period we will send the claim for coding review.

2nd Condition

If DOS falls after the global period.

We will ask the representative to reprocess the claim.

We will take a turnaround time and call Reference.

The modifier used in this denials are

1. 24 for Unrelated Evaluation and Management Service.

This modifier is used when patient come for Evaluation and Management Service under global Period
which is not related to surgery.

19. What is Timely filing limit expired denial?

Ans. Insurance will deny the claim with Denial code CO 29 – The time limit for filing has expired,

Whenever the claims submitted after the time frame.

We will call to Insurance.

We will take Denial Date and Claim Number.

 When did they received the claim?

What is their Timely Filing Limit?

1st Condition

If Insurance Received Claim under Timely Filing Limit.

WE will ask Representative to reprocess the claim.

2nd Condition

If insurance received claim after Timely Filing Limit.

We will check our billing software when did we filled the claim.

If we filled claim after Timely Filing Limit.

We will write-off the claim.

If we filled claim under Timely Filling Limit.

We will take appeal Limit and appeal address.

Call ref#

Action.

We will appeal with timely filing Limit Proof.(i.e. Eob and Clearing House Screenshot

20. What is no authorization denial ?

Ans. For every expensive treatment Doctor need to take prior authorization from insurance company

and that authorization number need to be billed on CMS 1500 form in BOX#23.

We will check our billing software whether we have authorization number available or not.

1st Condition

If we found authorization number available in our system.

We will call to insurance provide authorization number to representative and ask to send

claim for reprocess.

We will take turnaround time & Call Reference Number.

2nd Condition

If we don’t have authorization number available in our billing software.

We will verify place of Service (POS)

POS: Location where service was provided.

If place of service is 23 (Which is for emergency)

 We don’t require authorization number in emergency, so we will ask representative to send The claim
for reprocess.

If place of service is 21 (Which is for In-Hospital patient)

We will ask representative to send the claim for reprocess with authorization number

Available with hospital claim.

If they don’t have hospital claim or authorization number not available on hospital claim.

We will try to take authorization number from retro authorization department.

If we get authorization from retro authorization Dept. we will ask representative to send

Claim for reprocess. If we don’t get authorization then we will work as per client protocol.