CHAA - Certified Healthcare Access Associate Revenue Cycle Management 5 — Questions and Answers
Question 1: What is the primary purpose of prior authorization in the revenue cycle?
- To verify a patient's identity before registration
- To obtain payer approval before delivering certain services or procedures (Correct answer)
- To determine whether a patient qualifies for Medicaid
- To assign diagnosis codes to a scheduled encounter
Correct answer: To obtain payer approval before delivering certain services or procedures
Prior authorization requires the provider to obtain approval from the payer before rendering specific services. Without it, the payer may deny the claim entirely, making it a critical revenue cycle step that protects reimbursement.
Question 2: What does the metric 'days in accounts receivable' (A/R days) measure?
- The number of days a patient waits before receiving an appointment
- The average number of days it takes to collect payment after a service is rendered (Correct answer)
- The total dollar value of unpaid claims currently in the billing system
- The number of days a provider has to submit a claim before the filing deadline
Correct answer: The average number of days it takes to collect payment after a service is rendered
Days in A/R is a key revenue cycle KPI that reflects how efficiently a provider collects payments. A lower number indicates faster collections and healthier cash flow.
Question 3: What is the purpose of 'claim scrubbing' before submission to a payer?
- To remove duplicate patient demographic records from the EHR
- To verify that claims meet payer-specific formatting and coding requirements before submission (Correct answer)
- To collect patient copayments and deductibles at the point of service
- To assign clinical diagnosis codes to a patient's encounter
Correct answer: To verify that claims meet payer-specific formatting and coding requirements before submission
Claim scrubbing uses automated edits to catch errors—such as missing modifiers, invalid codes, or mismatched data—before a claim reaches the payer, reducing rejections and accelerating payment.
Question 4: What is the key difference between a claim rejection and a claim denial?
- Rejections involve coding errors; denials always involve medical necessity disputes
- A rejection is returned before processing; a denial means the claim was processed but payment was refused (Correct answer)
- Denials are only issued by government payers; rejections come from commercial insurers
- Rejections require a formal appeal; denials can be corrected and resubmitted immediately
Correct answer: A rejection is returned before processing; a denial means the claim was processed but payment was refused
A rejected claim never enters the payer's adjudication system—it is returned due to technical errors. A denied claim was fully processed but the payer determined it would not be paid, often requiring an appeal.
Question 5: What is the primary purpose of an Explanation of Benefits (EOB) in the revenue cycle?
- To authorize inpatient hospital admissions for scheduled surgeries
- To detail how the payer adjudicated a claim and what patient financial responsibility remains (Correct answer)
- To document a patient's clinical history for downstream billing purposes
- To assign a care coordinator to patients with complex or chronic conditions
Correct answer: To detail how the payer adjudicated a claim and what patient financial responsibility remains
The EOB is sent by the payer to both the provider and the patient after claim adjudication. It shows the billed amount, allowed amount, payer payment, and any remaining balance owed by the patient, driving the final billing step.
Question 6: In the revenue cycle, what does 'coordination of benefits' (COB) determine?
- How ICD-10 diagnosis codes are sequenced on a claim form
- Which payer is primary and which is secondary when a patient has more than one insurance plan (Correct answer)
- How hospital facility charges are reconciled with attending physician fees
- Which staff member is responsible for following up on outstanding patient balances
Correct answer: Which payer is primary and which is secondary when a patient has more than one insurance plan
COB rules establish the order in which multiple payers must pay when a patient carries more than one insurance policy. Billing the wrong payer first leads to denials and delays, making COB verification essential at patient access.
CHAA - Certified Healthcare Access Associate Revenue Cycle Management 5
What is the primary purpose of prior authorization in the revenue cycle?