BA Healthcare Assignment| Interview Questions| Done by Sonali K

1. What is Explanation of Benefits(EOB) ?

Ans: The EOB provides details about a medical insurance claim that has been processed and
explains what portion was paid to the health care provider and what portion of the payment,
if any, is the patient's responsibility. 
Topic Covered under: Healthcare Claim Life Cycle (Health Insurer Administrative System Work
Flow) Session-2

2. What are the differences between ICD 9 and ICD 10 ?

Ans: The basic differences between ICD-9 and ICD-10 are below:

ICD-9 ICD-10
ICD-9 CM has 14,025 3-5-character ICD-10 CM has 68,069 codes 3-7-character
alphanumeric diagnosis codes with 855 alphanumeric diagnosis codes with 2,033
categories. code categories.
ICD-9 PCS has 3,824 3-4-character ICD-10 PCS has 72,589 7-character
numeric procedure codes. alphanumeric procedure codes.

Topic Covered under: Healthcare Coding, Session -8

3. What is HIPAA?

Ans: HIPAA (Health Insurance Portability and Accountability Act) is United States legislation
that provides data privacy and security provisions for safeguarding medical information. The
law has emerged into greater prominence in recent years with the proliferation of health data
breaches caused by cyberattacks and ransomware attacks on health insurers and providers.

Topic Covered under: Healthcare Coding, Session -8

4. What is Medicare?

Ans: Medicare is a federal health insurance programme attached to social security. It is

available regardless of income. This programme is for:

a) All the US citizens who are 65 or older.

b) Covers people with disabilities.

c) People with end-stage diseases

Topic Covered under: Managed care organisation, Session-1

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BA Healthcare Assignment| Interview Questions| Done by Sonali K

5. What is Medicaid?

Ans: Medicaid is health insurance program funded jointly by states and the federal
government. It is administered by states, according to federal requirements.This programme
is for :

a) All the US citizens including eligible low-income adults, children, pregnant women, elderly
adults. Basically, it covers families and individuals with low income and resources.

b) Covers people with disabilities.

Topic Covered under: Managed care organisation, Session-1

6. What is Indemnity Plan?

Ans: Indemnity Plan or Fee for Service Plan is a part of private insurance health plan. Under
this plan there is no restriction of quality of services or accessibility of service.Indemnity
plans  allow you to direct your own health care and visit almost any doctor or hospital you
like. The insurance company then pays a set portion of your total charges.

Topic Covered under: Managed care organisation, Session-1

7. What are the different managed care plans?

Ans: Managed Care Plan is a part of private health insurance plan under which quality and
accessibility of services are managed through provider network. In other words, they have
contracts with  health care  providers and  medical facilities to provide  care  for members at
reduced costs. There are 4 types of managed care plan:

A) HMO (Health Maintenance Organisation)

B) PPO (Preferred Provider Organisation)

C) POS (Point of Service Plan)

D) CDHP (Consumer Directed Health Plan)

Topic Covered under: Managed care plans,Session-1

8. Explain Coordination of Benefits

Ans: Accumulating the benefits from all the health insurance plans wherever one is eligible,
provided the total benefit should not include more than 100%. In other words, coordination of
benefits (COB) allows plans that provide health and/or prescription coverage for a person to
determine their respective payment responsibilities (i.e., determine which insurance plan has
the primary payment responsibility and the extent to which the other plans will contribute
when an individual is covered by more than one plan).

Topic Covered under: Managed care plans,Session-1

Healthcare Domain Interview Questions – by Anil Kumar D

BA Healthcare Assignment| Interview Questions| Done by Sonali K

9. What are the differences between 4010 and 5010

Ans: 4010 and 5010 are different versions of EDI transaction. Basically the version 4010 lacks
changes that was required as per many companies. Since 2002, hundreds of change requests
have been submitted by industry stakeholders to improve functionality and to correct many
problems uncovered with Version 4010. These requests have not been addressed, either due
to the limitations of the Version 4010 base standard itself, or because they were identified
after the Version 4010 implementation. The volume of industry change requests only
continues to build. Eg. It does not provide a means for identifying an ICD–10 diagnosis code on
a professional claim. It also does not provide a means for identifying an ICD–10 procedure or
diagnosis code on an institutional claim. Whereas Version 5010 separates diagnosis code
reporting by principal diagnosis, admitting diagnosis, external cause of injury and reason for
visit, allowing the capture of detailed information (for example, mortality rates for certain
illnesses, the success of specific treatment options, length of hospital stay for certain
conditions.

10.Explain the terms Utilisation Management and Encounter Management.

Ans: Utilisation Management:

• Utilisation management is the evaluation of the appropriateness, medical need and

efficiency of health care services procedures and facilities according to established criteria
or guidelines and under the provisions of an applicable health benefits plan. Typically it
includes new activities or decisions based upon the analysis of a case.

• It describes proactive procedures, including discharge planning, concurrent planning, pre-

certification and clinical case appeals. It also covers proactive processes, such as concurrent
clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or
patient.

Encounter Management:

Encounter Management  delivers a consolidated platform that ensures the accuracy,

completeness and timeliness of encounter data submissions across all managed care programs
and lines of business.

Topic Covered under: Session-3,Healthcare Claims Processing

11. Explain the terms Pre-Autorization and Pre-Certification.

Ans: Pre-Authorization:

A pre-authorization under claim processing means that the insurance company will not pay
for a service unless the provider (a physician or hospital, usually) gets permission to provide
the service. Sometimes this permission is to ensure that a patient has  benefit  dollars
remaining (e.g., a payer may limit a patient to 12 chiropractor visits in a calendar year),
other times it is to ensure that a particular kind of service is eligible for payment under the
patient's contract. 

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BA Healthcare Assignment| Interview Questions| Done by Sonali K

A pre-certification requirement means that a payer must review the medical necessity of a
proposed service and provide a certification number before a claim will be paid. This is often
true with elective surgeries--a physician or nurse with the payer must review a physician's
order and the medical record to agree that a proposed procedure is medically appropriate.

Topic Covered under: Session-3,Healthcare Claims Processing

12. What is EDI?

Ans: Electronic Data Interchange (EDI) is the computer-to-computer exchange of business

data in standard formats. In EDI, information is organised according to a specified format set
by both parties, allowing a "hands-off" computer transaction that requires no human
intervention or rekeying on either end. The EDI standards are developed and maintained by
the Accredited Standards Committee (ASC) X12. The standards are designed to work across
industry and company boundaries. The X12 standards specify only the format and data
content of e-business transactions

13. Can you please name few Healthcare EDI transactions

Ans: Few healthcare EDI transactions are below:

Name of transaction Number Business use

Claim/encounter X12 837 For submitting claim to health plan, insurer, or
other payer
Eligibility inquiry and X12 270 and For inquiring of a health plan the status of a
response 271 patient.s eligibility for benefits and details
regarding the types of services covered, and for
receiving information in response from the
health plan or payer.
Claim status inquiry X12 276 and For inquiring about and monitoring outstanding
and response 277 claims (where is the claim? Why haven't you paid
us?) and for receiving information in response
from the health plan or payer. Claims status
codes are now standardized for all payers.
Referrals and prior X12 278 For obtaining referrals and authorizations
authorizations accurately and quickly, and for receiving prior
authorization responses from the payer or
utilization management organization (UMO) used
by a payer.
Health care payment X12 835 For replacing paper EOB/EOPs and explaining all
and remittance advice adjustment data from payers. Also, permits
auto-posting of payments to accounts receivable
system.
Health claims X12 275 For sending detailed clinical information in
attachments support of claims, in response to payment
(proposed) denials, and other similar uses.
Topics covered under:EDI ,Session-4
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BA Healthcare Assignment| Interview Questions| Done by Sonali K

14. What is a segment?

Ans: Segment is a structural part of any EDI transaction and is represented as a group of
related data elements. Being an intermediate information unit, EDI segment usually contains
one or more data elements. Segment starts with a three-character data identifier and ends
with a segment terminator.

15. What is a Loop?

Ans: In an EDI  document a “Loop” is simply a grouping of segments. A “Loop” may be

repeated but it does not need to be.

16. What is companion guide?

Ans: The purpose of Companion Guide is to provide the information necessary to submit
claims/encounters electronically. The guide is to be used in conjunction with the
Implementation Guide (TR3). The information in CG describes specific requirements for
processing data within the payer‟s system. The companion guide supplements, but does not
contradict or replace any requirements in the IG.

17.What is implementation guide?

Ans: Implementation guides define the structure and content of an 837 file / transaction set.
Each 837 format has its own implementation guide (837P, 837I, 837D). Each implementation
guide states the available levels, repeat values, and whether subordinate levels exist for the
transaction sets covered by the guide.

18. Can you please explain different segments in the 837 transaction file?

Ans: Submitter name and contact info, Receiver name, Billing provider, Subscriber
information, Payer name, Claim information, Rendering provider.

19.What are the different documents I would need to understand the 837 transaction
file?

Ans: There are 2 different types of documents to understand:

1) Companion Guide

2) Implementation Guide

20. Can you please explain the claim life cycle?

Ans: Claim Life Cycle: Attached Assignment 1

21. Can you explain few modules in facets which you can remember immediately?

Ans: Accounting, Billing, Hippa Privacy, Claims Process, Claims processing-ITS, Customer
Service, Dental Plans, Dental provider agreement, FSA Plan, Medical Plan, Pricing Profile,
Provider, Subscriber, Utilization Management and Workflow Configuration.

Healthcare Domain Interview Questions – by Anil Kumar D

BA Healthcare Assignment| Interview Questions| Done by Sonali K

22.What are ICD coding standards?

Ans: ICD codes provide more detailed information for measuring healthcare service quality,
safety and efficacy.  ICD-10-CM Standard code set for reporting and coding diseases, injuries,
impairments, other health problems and their manifestations

ICD-10-PCS -Will replace ICD-9-CM volume 3 and official coding guidelines for the following
procedures or other actions taken for diseases, injuries, and impairments on hospital
inpatients reported by hospitals: Prevention, Diagnosis, Treatment and Management

Software: AXURE | moc + ( trial video ) |balsimic|crystal UI

23. What is General Equivalence mapping?

Ans: General Equivalence Maps (GEMs) between ICD-9-CM and ICD-10-CM / PCS have been
developed as a tool to assist with converting large ICD-9-CM databases to ICD-10-CM / PCS.
GEMs can be used to convert payment / reimbursement systems, payment and coverage edits,
risk-adjusted logic, to track quality measures, to record morbidity & mortality and in research
applications involving trend data.

24. Explain HIPAA Security and Privacy rules

Ans: HIPAA regulations cover both security and privacy of protected health information.
Security and privacy are distinct, but go hand-in-hand.
• The Privacy rule focuses on the right of an individual to control the use of his or her
personal information. Protected health information (PHI) should not be divulged or
used by others against their wishes. The Privacy rule covers the confidentiality of PHI
in all formats including electronic, paper and oral. Confidentiality is an assurance that
the information will be safeguarded from unauthorised disclosure. The physical
security of PHI in all formats is an element of the Privacy rule.
• The Security rule focuses on administrative, technical and physical safeguards
specifically as they relate to electronic PHI (ePHI). Protection of ePHI data from
unauthorised access, whether external or internal, stored or in transit, is all part of
the security rule
25. What is HL7?

Ans: Health Level-7  or  HL7  refers to a set of international standards for transfer of clinical
and administrative data between software applications used by various healthcare providers.
These standards focus on the application layer, which is "layer 7" in the OSI model. The HL7
standards are produced by the  Health Level Seven International, an international  standards
organization, and are adopted by other standards issuing bodies such as  American National
Standards Institute and International Organization for Standardization.

26. What is HIE?

Ans: Health information exchange (HIE) is the electronic movement of health-related

information among organizations according to nationally recognized standards, with the goal
of facilitating access to and retrieval of clinical data by physicians, nurses, pharmacists, other
health care providers, and patients. HIE is intended to help providers:

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BA Healthcare Assignment| Interview Questions| Done by Sonali K

• Reduce medication and medical errors;

• Eliminate unnecessary paperwork and handling;

• Provide caregivers with clinical decision support tools for more effective
treatment;

• Eliminate redundant/unnecessary testing;

• Improve public health reporting and monitoring;

• Engage healthcare consumers regarding their own personal health information.

27. What is the difference between HIE and HIX?

Ans:HIX refers to health insurance exchange or marketplace insurance, HIX will allow
individuals to compare health insurance plans. HIE plays an important role in giving the
healthcare system a 21st  century upgrade. It gives providers—doctors, nurses, hospitals,
pharmacies, laboratories and others—the ability to exchange health information electronically
with other providers in a secure environment.

28. What is ARRA Act?

Ans: The American Recovery and Reinvestment Act of 2009 (ARRA) is an economic stimulus bill
created to help the United States economy recover from an economic downturn that began in
late 2007. ARRA allocates $787 billion to fund tax cuts and supplements to social welfare
programs as well as increased spending for education,  health care  , infrastructure and the
energy sector. It was developed

• To preserve and create jobs and promote economic recovery,

• To assist those most impacted by the recession, provide investments needed to

increase economic efficiency by spurring technological advances in science and health.

• To invest in transportation, environmental protection, and other infrastructure that

will provide long-term economic benefits.

• To stabilize State and local government budgets, in order to minimize and avoid
reductions in essential services and counterproductive state and local tax increases.

29. What is HITEC Act?

Ans: The HITECH (Health Information Technology for Economic and Clinical Health) Act of
2009 is legislation that was created to stimulate the adoption of  electronic health
records  (EHR) and the supporting technology in the United States. President Barack Obama
signed HITECH into law on Feb. 17, 2009, as Title XIII of the American Recovery and
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BA Healthcare Assignment| Interview Questions| Done by Sonali K

Reinvestment Act of 2009 (ARRA) economic stimulus bill. One of the major impacts of the
HITECH Act is that the rate of EHR adoption for eligible hospitals increased from 3.2% to 14.2%
from 2008 to 2015. Prior to the HITECH Act, the rate of adoption was low -- only 10% of
hospitals and 17% of doctors had adopted the technology, according to a report in the
journal Health Affairs.

The HITECH Act also expanded privacy and security provisions that were included
under  HIPAA, holding not only healthcare organizations responsible for disclosing breaches,
but holding their business associates and service providers responsible, as well.

30. What is EHR?

Ans: EHR is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered
records that make information available instantly and securely to authorized users. While an
EHR does contain the medical and treatment histories of patients, an EHR system is built to
go beyond standard clinical data collected in a provider’s office and can be inclusive of a
broader view of a patient’s care. EHRs can:

• Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization

dates, allergies, radiology images, and laboratory and test results

• Allow access to evidence-based tools that providers can use to make decisions about a
patient’s care

• Automate and streamline provider workflow

• One of the key features of an EHR is that health information can be created and managed
by authorized providers in a digital format capable of being shared with other providers
across more than one health care organization. EHRs are built to share information with
other health care providers and organizations – such as laboratories, specialists, medical
imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so
they contain information from all clinicians involved in a patient’s care.

31. What is the difference between EHR and EMR?

Ans: An  electronic medical record (EMR)  is a single practice’s digital version of a
patient’s chart. An EMR contains the patient’s medical history, diagnoses and
treatments by a particular physician, nurse practitioner, specialist, dentist, surgeon
or clinic. It would be easy to remember the distinction between EMRs and EHRs, if you think
about the term “medical” versus the term “health.” An EMR is a narrower view of a patient’s
medical history, while an EHR is a more comprehensive report of the patient’s overall health.

Here are a few more ways EMRs and EHRs differ:

i) An EMR is mainly used by providers for diagnosis and treatment.

ii) EMRs are not designed to be shared outside the individual practice.
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BA Healthcare Assignment| Interview Questions| Done by Sonali K

iii) EHRs are designed to share a patient’s information with authorized providers
and staff from more than one organization.

iv) EHRs allow a patient’s medical information to move with them to specialists,
labs, imaging facilities, emergency rooms and pharmacies, as well as across
state lines.

32. What is Meaningful Use?

Ans: Meaningful use consists of a set of standards which govern how electronic health records
are used by healthcare providers such as physicians, clinicians and hospitals. According to the
Centers for Disease Control and Prevention,  meaningful use is defined by a series of policy
priorities for EHRs, including improved quality, safety and efficiency of care,
better  coordination between providers, ensured privacy and security of personal
information, and the engagement of patients in their own health.

33. What are the deadlines associated with the implementation of EHR and Meaningful
use?

Ans: Three stages of Meaningful Use

• Stage 1 (2011): Capture/Share Data

• Stage 2 (2013): Advanced Care Processes with Decision Support

• Stage 3 (2015): Improved Outcomes

34. Explain the Facets data model in simple terms

Ans:

35. What is Pharmacy benefits Management?

Ans: Pharmacy benefit managers (PBMs) are private companies that administer pharmacy
benefits and manage the purchasing, dispensing and reimbursing of prescription drugs. PBMs
provide their services to health insurers or to large health care purchasers such as public
employee systems, other government agencies and labor union trust funds. PBMs contract
with managed care organizations, self-insured employers, insurance companies, unions,
Medicaid and Medicare managed care plans, the Federal Employees Health Benefits Program
and other federal, state, and local government entities (e.g. CalPERS) to provide managed
prescription drug benefits.

36. What are Procedure codes?

Ans: Procedure codes  are a sub-type of medical classification used to identify specific
surgical, medical, or diagnostic interventions. The structure of the codes will depend on the
classification; for example some use a numerical system, others alphanumeric.

or

• Procedure codes are that define what services have been performed.
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BA Healthcare Assignment| Interview Questions| Done by Sonali K

• On medical claims, they are also called Current Procedural Terminology (CPT) codes.

• Procedure codes give a precise description of the type of service performed. They are also
the mechanism by which the exact level of reimbursement is determined. Hospital claims
procedure codes are commonly referred to as HCPCs.

37. What are diagnosis codes?

Ans: Diagnosis  codes are the translation of written descriptions of diseases, illnesses and
injuries into  codes  from a particular classification. In medical classification,  diagnosis
codes are used as part of the clinical coding process alongside intervention codes.

or

Diagnosis Codes describe the patient’s condition or the reason the services were performed.
Although no dollar amounts are attributed to the ICD-9 codes (International Classification of
Diseases) they do indicate medical necessity of a particular service.

Example:

• Diagnosis code V20.2 – Routine infant or child health check

• Diagnosis code 650 – Delivery in a normal complete case.

38. What are Taxonomy Codes?

Ans: Taxonomy Codes are also called Specialty Codes, and are the 9-digit numbers assigned
under the HIPAA provisions to health care providers, in order to digitally encode their
specialty in order to facilitate electronic billing.

• Home Health Agency – 251E0000X

• Adult Day Health – 261QA060X

• Hospital, General – 282N0000X

38. What is the difference between CM and PCS codes?

39. How are procedure and diagnosis codes represented in the ICD 9?

40. What are modifier codes?

Ans: Modifiers indicate that some specific circumstances has altered a service or a
procedure performed, but has not changed the definition or code. A modifier may indicate
that a procedure deserves payment at the full fee schedule amount or that there was less
work than is included in the CPT code description.

• 51 – Multiple procedure

• 76 – Repeat procedure by the same physician

• 77 – Repeat procedure by another physician

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• 82 – Assistant surgeon (when qualified resident is not available)

•
41. What are location codes?

Ans: Location Codes indicate where the service was rendered. Some commonly used location
codes and their conversions/meanings are listed below:

11 – Office

12 – Home

20 – Urgent Care center

21 – Inpatient Hospital

22 – Outpatient Hospital

23 – Hospital Emergency Room

42. What is Adjudication?

Ans: Adjudication literally means making a decision. Claim Adjudication is a term used in the
Insurance Industry to refer to the process of paying claim submitted or denying them after
comparing claims to the benefit or coverage requirement.

43. What is benefits enrolment?

Ans: It is the period of time when employees of the companies or organizations have to apply
for either a new plan or can make changes to the existing benefits provided by insurance
companies. This usually occurs once a year.

Healthcare Domain Interview Questions – by Anil Kumar D