Revenue Cycle Management 5 Flashcards
6 cards from real CHAA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Revenue Cycle Management 5 flashcards as text
What is the primary purpose of prior authorization in the revenue cycle?
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.
What does the metric 'days in accounts receivable' (A/R days) measure?
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.
What is the purpose of 'claim scrubbing' before submission to a payer?
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.
What is the key difference between a claim rejection and a claim denial?
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.
What is the primary purpose of an Explanation of Benefits (EOB) in the revenue cycle?
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.
In the revenue cycle, what does 'coordination of benefits' (COB) determine?
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.